Incident investigation·April 14, 2021

Licensing Program Analysts (LPAs) Michael Hood and Bethany Mirlohi met with Acting Administrator, Sharon Monck, to conduct a case management visit. The purpose of the visit is to follow-up on three incident reports that were received by the Department. According to first incident report, on 1/6/2021, hospice nurse was scheduled to apply a fentanyl patch for resident R1 but found that the facility did not have the patches necessary to administer the medication. LPAs interviewed medication technician (Med-Tech) and nurse, as well as reviewed R1's MAR and controlled medication binder, regarding incident on 1/6/2021. LPAs observed that fentanyl patch was administered on 1/3/2021. Med-Tech stated that fentanyl patch needs to be re-administered every 72 hours. Med-Tech stated that facility staff did not communicate with hospice regarding the reorder for fentanyl patches for R1. Due to lack of communication, R1 did not receive medication on schedule. According to second incident report, on 3/11/2021, a PM shift medication aide reported that they forgot to administer medication, Norco 10-325 mg, for R2 on 3/10/2021. Medication count on Narcotic sheet did not match medication amount on hand. An investigation was conducted by the facility, which determined that R2 missed medication on 3/8/2021 and 3/10/2021. In addition, during interviews with staff, LPAs found R2 to have a missing tablet for the same medication. According to third incident report, on 3/23/2021, hospice nurse noticed during administration of fentanyl patch for R2 that patch was not changed on 3/20/2021 by a hospice nurse. ** Report continued on 809-C ** LPAs reviewed MAR for R2 and confirmed missing administration of fentanyl patch on 3/20/2021. MAR was missing information regarding reasons for missed medication. LPAs reviewed resident R3's medications in relation to R3's MAR. LPAs observed R3 had an order for medication Loperamide. However, ordered medication was missing in medication cart. LPAs also observed 2 medications for R3 in cart that had no active orders in R3's MAR. Incident reports indicated that in-services were completed for staff regarding medication errors and communication with hospice. Staff were notified to inform hospice if medication supply was running low. As a result of today's inspection, deficiencies are being cited in regards to medication errors per California Code of Regulations, Title 22, on 809-D. Exit interview was conducted with Acting Administrator. A copy of this report and appeal rights were provided. The Acting Administrator’s signature on these forms acknowledges receipt of these documents.