Follow-up·April 17, 2023

On 4/17/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management visit to follow-up on recent incident reports submitted to the regional office. LPA met with the nurse and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions. LPA complied with facilities masking policy. On 4/13/23, the regional office received an incident report that stated that on 04/03/2023 at 5:50 am. Noc Medication care manager (S1)gave the a new resident (R1) levothyroxine 75 mcg. The resident has an order for levothyroxine 50 mcg, R1 received an additional 25 mcg. Resident (R1) self-manages R1's own medication. R1 suffered no ill effects as a result and R1's physician recommended continue with regular scheduled doses. S1 received an in-service regarding the medication errors. The facility also submitted a incident report regarding a medication issue which occurred on 4/8/23 regarding PRN medication for R2 administered by S1. R2 had an original prescription for half a 5 mg dose of pain medication. During a follow-up visit R1's physician gave a verbal order for a full tab of the same medication. On 4/14/23, R1's physician provided a written order for a full tablet. However, records review found that the facility was in possession of a hospital discharge summary stating a half tab be given for R1's pain on 4/8/23. This summary was not signed by the physician. Report continued... Records review and interviews conducted by LPA on 4/17/23 found that a medication error occurred on 4/3/23 involving R1 and S1, the error was not reported to CCL within 7 days of the occurrence of the 4/3/23 medication error and the facility did not have a signed physician's order for R2's medication given on 4/8/23. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Stephanie Jameson . Copy of this report and appeal rights provided.