Incident investigation·July 17, 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 Business Office Director William Lopeman. LPA then met and spoke with Executive Director Caroline Senteno, who arrived shortly after. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 07/03/2023). According to the LIC624: on the evening of 06/21/2023, a joint error by Staff #1 (S1) and Staff #2 (S2) led to Resident #1 (R1) eating/ingesting a topical cream, rather than that cream being applied to their skin (which is how it was prescribed). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. R1 was sent to a local hospital via 911 for further evaluation. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA reviewed pertinent care, administrative, and hospital records. LPA also interviewed R1 and relevant staff. Per their latest LIC602 Physician’s Report (dated 02/28/2023), R1 was diagnosed with “Lewy Body Dementia” and required staff assistance with taking their prescribed medications. Per assessment/care plan (dated 05/12/2023) which Licensee authored, R1 experienced forgetfulness and confusion and required staff assistance with taking their prescribed medications. Despite R1’s dementia diagnosis, they were alert and oriented enough participate as a reliable historian/interviewee about the incident. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Interviews, corroborated by records, showed: S1 did not follow internal medication procedure, and miscommunication occurred between S1 and S2, which materially contributed to R1 being able to ingest the cream. Facility staff timely notified R1’s prescribing physician and responsible party. R1 developed abdominal pain, and 911 was timely called. R1 was evaluated at a nearby hospital but was not admitted overnight. After R1 discharged back to the facility, staff continued to observe them. R1 had no further physical complaints/problems. Prior to LPA’s site visit, Licensee had formally disciplined S1 and provided verbal coaching/counseling to S2, based on its internal investigation of the incident. Licensee had also retrained its medication technician team at large on accurate medication pass policies/procedures. A preponderance of evidence exists to show that during the above incident, Licensee’s staff did not give R1 their medication via the route that it was prescribed. The medication error triggered temporary abdominal pain, but did not result in lasting injury/illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D page). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation regarding Reporting Requirements (refer to the LIC 9102-TV page). An exit interview was conducted with Senteno, to whom a copy of this report, the LIC 809-D, the LIC 9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.