Incident investigation·April 15, 2024

On 04/15/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 03/15/24 for resident (R1) for medication error as reported by facility on 03/21/24 by Incident Report ( LIC624). LPA met with Operations Director, Galina Chikivchuk and explained the reason for visit. After staff interviews and records reviewed, it was determined that staff (S1) gave extra medication dose of Divalproex Sodium during med pass on 03/15/24 around 8am. Incident report stated that S1 accidentally added an extra pill of Divalproex Sodium in R1s medication box during morning med pass on 03/15/24 around 6am while dispensing the morning medications for R1. Facility reported this medication error to R1s family, physician and other agencies as required. Incident Report indicated that R1s doctor ordered a hold on the Divalproex Sodium until further notice after this incident on 03/15/24. Based on this information, deficiency is cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties. Exit interview conducted. Appeal rights provided. Copy of the report left at facility.