Incident investigation·March 20, 2024

LPA Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself, and discussed the purpose of the visit with Executive Director Candi Laird. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 03/13/2024). According to the LIC624: during the morning of 03/12/2024, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. These medications were instead prescribed to Resident #2 (R2). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA collected copies of and reviewed pertinent care records, training records, and physician correspondence. LPA also interviewed relevant staff. Staff interviews aligned to show: On the morning of 03/12/2024, S1 was a newer Medication Technician and recently underwent medication pass training with a nurse manager. At breakfast time, Staff #1 approached R1 and asked R1 to verify his identity, R1 agreed to the wrong identity. R1 then ingested medications which were not prescribed to them. Staff quickly recognized the error and timely notified R1’s primary care physician (PCP). Staff measured R1’s blood pressure multiple times, finding it was consistently within a safe range. Staff continued to closely observe R1 for 72 hours and R1 had no adverse reactions. [Continued on 809-C] [Continued from 809] Personnel records showed that Licensee provided one-on-one remedial medication pass training to S1 following the incident. No citations were issued at the time of visit however one (1) Technical Violation (TV) was issued.. An exit interview was conducted with Executive Director Candi Laird, to whom a copy of this report, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.