Follow-up on corrections·April 14, 2023

On April 14 2023, Licensing Program Analyst DeAnna Williams Lyons arrived to issue a citation. LPA met with Executive Director, Henry Cole, and informed him the reason for the visit. Prior to initiating the visit LPA completed COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and wore an N-95 mask for Personal Protective Equipment (PPE). During a complaint investigation at this facility, it was learned that facility staff administered R1 (2) two discontinued medications in conjunction with (2) two newly ordered medication resulting in R1 sustaining hypoglycemia causing R1 to be hospitalized with ICU admission. The facility did not follow its medication administration process resulting in a medication administration error for R1. Based on the review of the medical records, DSS’ investigative findings, and other miscellaneous documents, the facility failed to follow its medication administration process to ensure there is no medication errors which resulted in serious bodily injury. R1's hypoglycemia, hospitalization, and ICU admission as evidenced by the following clinical relationship to the violation: The facility failed to ensure staff was following the facility’s medication administration process (1 st check). Medication transcription in MAR was done by the MT who received the PCP order for new medication, but facility staff did not discontinue R1's discontinued mediations on R1's MAR. To continue see 809-C... The facility failed to ensure 2 nd check by MT was done to compare the new medication orders and discontinued medication orders with the Physician order and MAR before administering R1's medications. Based on records reviewed, the facility failed to follow medication administration process resulting in R1 sustaining a medication error causing hospitalization. As a result of R1's hospitalization, the violation warrants an immediate civil penalty assessment in the amount of $500. The facility is advised that additional civil penalties are under Departmental review based on Health and Safety code §1569.49 and may be assessed at a later date due to R1 sustaining serious bodily injury while in care. Citations are issued today based on Title 22 regulations and documented on the attached LIC809-D. Exit interview and appeal rights provided.