Incident investigation·June 7, 2024

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Bonghabih Smith. Today's visit was in response to a licensee self-reported medication error. An Unusual Incident Report was received at the CCLD San Diego Regional Office on 4/11/2024. [See LIC 811 Confidential Names List for a description of residents]. Per the self-reported document, on 4/10/2024 staff (S1) administered resident’s (R1) medication. Prescription stated that R1 is to receive two (2) tablets, R1 was given one (1) pill instead due to the bubble pack only containing one pill. Medication error was acknowledged, and staff requested that pharmacy send correct bubble pack dose. During today’s visit, LPA performed a brief welfare check on residents, finding no safety concerns. LPA conducted interviews and reviewed records. Interview revealed that on 4/10/24, S1 overlooked the fact that the bubble pack contained one pill instead of 2 and incorrect dosage was administered to R1. On 4/15/2024, S1 was written up for “disregarding safety rules & practice” and counseled on 7 rights of medication administration. One (1) deficiency was cited per California Code of Regulations, Title 22, (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Executive Director. An exit interview was conducted with Executive Director, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).