Incident investigation·September 4, 2024

On 9/4/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 07/02/2024 . LPA met with Executive Director, Elena Cuevas (ED) and explained purpose of visit. The incident report detailed an occurrence in which resident R1 was mistakenly given eye drops intended for another resident. This error was made by a staff member on duty (S1), who promptly reported the incident as required. Note that the incident was reported to CCLD within the reporting requirement. Upon a review of the incident report and R1's medication records, it was verified that R1 did not have a prescription for the eye drops that were mistakenly administered on June 26, 2024. During the visit, staff member (S2) provided additional details, explaining that following the incident, R1’s hospice provider was promptly notified. A skilled nurse from the hospice subsequently assessed R1’s condition. According to S2, the hospice provider did not issue further instructions but continued to monitor R1 to ensure their well-being after the error. S2 also clarified that the eye drops administered were antibiotics that had been discontinued prior to today's visit. A comprehensive review of R1’s care notes corroborated that there were no adverse reactions or negative effects from the administration of the eye drops. Furthermore, an interview with the Executive Director (ED) and a review of the incident report revealed that S1, who was responsible for the medication error, was removed from medication duties after the incident. S1 also underwent additional training to prevent future occurrences of such errors. Per California Code of Regulations, Title 22, deficiency is being cited during today's case management inspection. Note that failure to correct the citation can result in civil penalties. An exit interview was conducted with Elena and a copy of this report and appeal rights were provided to the facility.