Incident investigation·May 4, 2023

On 5/4/23 at 9:10am, Licensing Program Analyst (LPA) Kevin Gould conduced and unannounced Case management inspection to address concerns with reported medication administration errors reported on 4/16/2023 and 4/23/2023. LPA met with Neal Torres and together discussed the reported incidents. It was disclosed to LPA that one resident has a complex insulin administration schedule and the two errors were made by two different staff members. in one instance the incorrect insulin was administered, the error was noticed immediately and physician and poison control were contacted at instructions followed. On the second instance the insulin was administered 4 hours earlier in conjunction with another insulin dose. Physician and poison control were contacted at instructions followed. One of the staff members has already participated in medication administration retraining. the second staff member will receive medication administration training in the near future. The facility has informed LPA that they have installed a new regimen for insulin administration and they are in the process of approving and adopting an electronic medication administration record (MAR). Per California Code of Regulations, Title 22, the following deficiency is cited and due to a previous citation in the past 12 months, a civil penalty is issued. An exit interview was conducted an a copy of this report and appeal rights were left at the facility.