complaint·October 16, 2024

around 10:00 AM. S1 reported they prepared the medications in cups, left the medications on a meal tray on the kitchen counter, stepped away to use the restroom, and when they returned, noticed one tray was gone about five (5) to ten (10) minutes later. S1 reported they observed R1 had the missing tray and immediately noticed the medications were incorrectly given. S1 reported as a result of the medication error, Manager, Faiz Khan, and R1's nurse practitioner were contacted. S1 reported the nurse practitioner recommended R1 be sent to the emergency room due to the amount of medications the resident took, which was about ten (10) pills. S2 was interviewed and confirmed R1 was incorrectly given the wrong medications after they (S2) issued the wrong meal tray to the resident. S2 reported they could not read the name on the tray, though believed it was R1's tray based on the arrangement the tray was in. S2 reported they did not observe R1 to have any symptoms after taking the incorrect medications. S2 reported the manager, Faize, and the nurse practitioner were contacted. S2 reported emergency services was contacted after R1's blood pressure had been monitored and once the resident agreed to be sent out to the hospital. R1's Admission agreement revealed the resident was to receive assistance with medication administration. An After Visit Summary that was on file at the facility revealed R1 was hospitalized on 10/09/2024 for both Dizziness and Drug Overdose. No diagnosis was listed on the report. Medical records were subpoenaed on 10/14/2024; however, they were not obtained prior to the closure of the investigation. An Unusual Incident/Injury Report (UIR) was obtained from the facility on 10/10/2024. The report revealed the date of the incident was 10/09/2024. The report revealed staff accidentally took another resident's medication cup with the tray to R1. The report revealed manager, Faiz, the Administrator, Musarrat Khan, and R1's nurse practitioner were notified of the incident. The report revealed R1's vitals were immediately checked, and the resident was observed to be stable and their normal self. The report revealed R1 was later transported to the hospital for observation. Therefore, based on interviews and records, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This violation posed a potential threat to the health, safety, and personal rights of the resident in care. A citation will be issued. An exit interview was conducted; this report was reviewed with Administrator, Musarrat Khan, and a copy, along with the LIC 811, LIC 9098, and instructions on appeal rights were provided.