Incident investigation·July 26, 2023

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following on a self-reported incident report received in the Orange County Regional Office (OCRO) on 07/24/23 regarding a medication error involving Resident #1 (R1). LPA met with Administrator (AD) Gerry Vadinais and Health Services Director (HSD) Carri Collins and discussed the purpose of the inspection. The incident report states that on 07/17/23, R1 received twice the dose of Oxycodone. R1 was to receive one-half of a tab and instead received a full tab. When the medication error was noticed, facility staff conducted checks on R1 and noted no adverse reaction. Facility staff then checked on R1 every 2 hours for the next 72 hours. R1’s family and doctor were immediately notified. The Medication Technician who committed the error, Staff #1 (S1), was immediately pulled from dispensing medications and assigned to be fully retrained in medication management procedures. As of 07/21/23, R1 had no adverse reactions. During today’s inspection, LPA interviewed HSD who provided the following information: the medication error was noticed approximately one and a half hours after administration during the re-count of medications; R1’s doctor advised that it was not necessary to send R1 to the hospital and it was OK for R1 to receive the full tab of Oxycodone as R1 had been previously prescribed a full tab but the prescription was changed to one-half of a tab upon R1’s request; and as of 07/26/23 R1 is doing fine. During today’s inspection, LPA conducted a health and safety check on R1 and confirmed R1 was doing well and observed no health and safety issues. Per AD and HSD, S1 began the re-training process, but resigned after a few days. HSD stated that all Medication Technicians receive monthly training. 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.