Incident investigation·June 19, 2023

On 06/19/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 06/04/23. LPA met with Director of Health (DOH) , Eva Bowlin and explained reason for visit. Special Incident Report (LIC 624) submitted by facility on 06/05/23 to CCL stated that R1 was send to hospital on 06/04/23 around 8.30am, after R1 was given wrong medications by staff. Incident report indicated that R1 was given medications, Fenofibrate 54mg- 1 tablet, and Fluoxetine 10 mg- 1 tablet which were NOT prescribed by R1s physician. Staff notified immediately facility’s management regarding the medication error and facility send out R1 to hospital to seek medical care. R1 came back to the facility same day with no changes to their health and they were back to their baseline. Facility notified R1s physician and responsible party on 06/04/23 regarding medication error. Based on incident report, staff interviews and medication record review from the facility, R1 was given medications, Fenofibrate 54mg- 1 tablet, and Fluoxetine 10 mg- 1 tablet by mistake. It was determined that facility administered wrong medications to R1 which poses a immediate heath and safety risks to residents in care. Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D. The report was reviewed, appeal rights and a copy of this report was left at the facility.