complaint·February 15, 2024

CONTINUED...S1 reported placing R1’s medication and a second resident, Resident 2 (R2)’s medication into white cups with their room numbers written on it. S1 signed off on both R1 and R2 taking their medications based on verbal information received from S2. S1 and S2 did not physically see residents take their medications. On the morning of August 13, 2023, R1 saw a white cup with medications on the nightstand and assumed they were for them and ingested them. When S1 came in to do R1’s morning medication disbursement, S1 found out S2 had left medications for R2 on R1’s dresser and didn’t distribute them like they had said they did the night before. Shortly after taking the wrong Medications, R1 became lethargic and unresponsive and was transported to St.Jude Hospital and returned to the facility later that night. On August 15, 2023, approximately two days after being hospitalized for ingesting the wrong medications, R1 was getting showered by a caregiver and once again became lethargic and unresponsive and was transferred to St. Jude Hospital. St. Jude Hospital medical records state R1 suffered from a stroke and was diagnosed with a cerebral blood clot causing R1 to undergo surgery. Medication Administration Records (MARs) for R1 show R1 had a prescription for Eliquis to be taken 1 tablet by mouth twice daily. Interviews conducted with Administrator Melanie Washington confirmed R1 missed their evening dose of medication on 8/13/23 due to returning back to the facility late after being hospitalized. The morning of 8/15/23, facility staff were prepared to administer R1’s medications but did not due to R1’s medical emergency causing them to be re-hospitalized. Due to R1 being hospitalized two times as a result to taking the wrong medication, R1 missed their Eliquis medication doses. Per Medical Expertise received by the Department, R1’s missed Eliquis medication was a contributing factor to R1 having a blood clot/stroke. Upon finding out R1 ingested another resident’s medication, Facility Administrator Melanie Washington conducted an internal investigation and determined that facility protocol had not been followed. Both S1 and S2 were terminated. Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegation that staff did not make medication inaccessible to resident, resulting in hospitalization has been Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). An exit interview was conducted, and a copy of this report, 9099-D Page, and appeal rights was left at the facility.