Incident investigation·January 13, 2023

This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 01/04/23 regarding a medication error involving Resident #1 (R1). LPA met with Administrator (AD) Glen Goldsmith and discussed the purpose of the inspection. The incident report states that on 12/31/22, R1 received the wrong medication at bedtime, facility staff notified a doctor who advised facility staff to monitor R1 and report any changes, R1 was monitored, and additional training will be conducted to avoid future medication errors. During today’s inspection, LPA conducted a health and safety check on R1, observed no health and safety issues, and observed R1 was in good health and good spirits. LPA inspected the medication room, observed it to be clean and organized, and observed no health and safety issues. LPA interviewed AD who confirmed the information in the incident report and provided the following information: the medication error involved R1 receiving their own medications at the wrong time; on that day, R1 received their AM medications in the morning but in the PM R1 was given the next day’s AM medications instead of their PM medications; the error was made by Staff #1 (S1); the facility notified the doctor and observed R1; there were no complications with R1 and the doctor did not recommend sending R1 to the hospital; and the facility is completely retraining S1. LPA reviewed training records showing that S1 began the retraining process on 01/05/23 and completed the process on 01/10/23. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.