Follow-up on corrections·May 29, 2024

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Sabrina Priesman Executive Director.  During today's visit, LPA observed residents in care, conducted a health and safety check, reviewed records, and interviewed staff and residents. The purpose of today's visit was to conduct follow up regarding a self reported incident. On May 18, 2024, the Department received an incident report from the facility describing an incident that occurred on May 16, 2024, where staff discovered that Resident 1's (R1's) medication was not being administered as ordered. [Please refer to the LIC811 Confidential Names List to identify individuals]. Interviews with S2 revealed that the resident is not a self-administrator of medications.  The health and service plan reflects that R1 is not a self-administrator of medications and R1's medications were ordered from P1. S2 stated that S1 noticed that R1's medication was running low and S1 ordered the medication from P1. R2 directed S1 to call P2 to have the medication delivered to the facility. P2 delivered the incorrect medication, the correct medication was delivered on May 19, 2024 and R1 starting taking the medication on May 19, 2024. Interviews with S2 and review of R1's electronic medication administration record (E-MAR) revealed that the medication was not given to R1 from May 12, 2024 through May 18, 2024. The Physician was notified of the medication error and staff was directed to monitor R1 for no adverse side effects of the missed medication. Interview with S2 revealed that R1 had not been experiencing any adverse effects due to the medication not being administered not as ordered. The following deficiency for medication administration is being cited and noted on the attached LIC809-D page. An exit interview was conducted with Executive Director Sabrina Priesman whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).