Incident investigation·August 29, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Services Director Dennis Prejusa. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/07/2023). According to the LIC624: during the morning of 06/24/2023, 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, finding that they were alert, talkative, and safe. LPA also reviewed pertinent facility care records and interviewed relevant staff. Per their latest LIC602 Physician’s Report, R1 was diagnosed with Dementia, was “confused/disoriented,” and required staff assistance with storing and taking their prescribed medications. Due to their baseline memory loss, R1 was not able to recall specific details about the incident. Interviews and care records revealed: During the time frame of the incident, R1 and R2 each resided in the facility’s secured memory care section. S1 had been in their medication technician role for about one (1) month, but they usually worked in the facility’s assisted living section; S1 was thus less personally familiar with who R1 and R2 were. R1 went by a colloquial nickname (“Name A”), which coincidentally, was also the legal first name of R2. On the morning of 06/24/2023, S1 approached R1 and asked them if they were Name A. R1 answered yes, so S1 gave R1 six (6) medications which belonged to / were prescribed to R2. R1 ingested these tablets. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Shortly after, S1 realized their error and timely notified their supervisors, who themselves timely notified R1’s primary care physician (PCP) and responsible person (RP). Facility staff followed the PCP’s instructions to observe R1 and continue measuring their blood pressure and pulse vital signs, and to call 911 if certain symptom criteria were met. Date and time-stamped progress notes evidence that facility staff measured R1’s vital signs fourteen (14) times over the next 12 hours. R1’s vital signs remained stable, and they did not display any adverse symptoms. The medication errors which affected R1 on the morning of 06/24/2023 did not prevent R2 from receiving their respective prescribed medications on that date. Staff interviews and training records showed: Licensee utilized digital Electronic Medication Administration Records (EMARs), which medication technicians accessed via password-protected laptops atop the facility’s rolling medication carts. S1 was trained to verify R1’s identity before handing them their medications. LPA observed that a legible, color photograph of R1 had indeed been uploaded to R1’s EMAR record. Manager interview confirmed that this photograph of R1 was accessible to S1 during the 06/24/2023 incident. After the incident, Licensee temporarily removed S1 from medication pass duties. Licensee counseled and retrained S1 on accurate medication pass procedures, before reinstating them in those tasks. On 07/06/2023, Licensee retrained its larger medication technician team on accurate medication pass procedures, to include verifying the identity of each resident before handing medications to that resident. A preponderance of evidence exists to show that during the above incident, License’s staff (S1) did not assist a resident (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care. S1’s medication errors did not result in observable injury or illness to R1. One (1) deficiency was thus cited, per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was joined developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements. An exit interview was conducted with Prejusa, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.