Incident investigation·April 8, 2025

On April 8, 2025 (4/8/25) , Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Administrator (Admin) Allison Lopez. On 3/22/25, the department received an incident report regarding a medication error for R1. The incident report stated that on 3/15/25, at approximately 6 AM, R1 was given and ingested a medication that was prescribed for R2. LPA interviewed Admin. Admin stated that the internal inquiry found that medication technician (Med tech) S1 did not follow medication administration procedures. Med techs are instructed to do a "live pour "for each resident and to verify the right resident,medication, time, dose, and route before dispensing medications. It was reported to LPA that S1 apparently pre-poured medications and gave R1 medications intended for R2. When S1 realized they had made the error, appropriate notification were made and R1 was monitored for possible side effects. S1 was removed from medication administration and R1 suffered no adverse effects. All medication procedures have been reviewed with all current med techs. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided