Incident investigation·July 2, 2021

On 7/2/2021 LPA Todd Tryon arrived at the facility to conduct a case management visit. LPA met with ED Christine Sallee. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPAs were screened by facility staff upon entering the facility. The purpose of this visit was to discuss Incident Reports submitted for 5/12/2021 and 5/19/2021. Through review of reports and interview with staff, LPA found the following: On 5/12/2021 it was reported that resident R1 received the wrong medication. R1 received Lorazepam 0.5 mg instead of Alprozolam 0.5 mg. This situation was corrected noted, resident was monitored and showed no adverse reactions. On 5/19/21 staff found that an order for resident R2 was entered incorrectly on the electronic Medication Administration Record (MAR). Order was for Amlodipine 10 mg; but had been entered as Amlodipine 20 mg; therefore resident had received the wrong dosage. MAR was corrected, resident was monitored and showed no adverse reactions. As per review of Incident Reports and interview with ED, staff have received additional training regarding Medication Management. The following deficiencies are being cited as per Title 22 Regulations. Appeal rights were proviced, exit interview conducted. This is the second time this particular regulation has been cited in the past 12 months. Therefore, a Civil Penalty is issued.