Incident investigation·February 6, 2024

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 Executive Director Randal Newton. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 01/17/2024. According to the LIC624: during the morning of 01/17/2024, an error by staff led to Resident #1 (R1) receiving double (i.e., twice as much) of their prescribed dose for each of eight (8) of their medications. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. The overdoses did not result in any adverse health consequence for R1. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe and well. LPA collected copies of and reviewed pertinent care and personnel records. LPA also interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 04/05/2022), R1 was able to administer their own prescription medications. However, according to the latest Service Plan (dated 09/23/2023) which Licensee prepared on R1, they required assistance with medication management. Manager interview also confirmed that R1 now had mild memory impairment and was paying Licensee to help them take their medications during the time of the incident. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Staff interview and records showed: Around 7:30 AM on 01/17/2024, Staff #1 (S1), who was assigned to the facility’s second floor, gave one dose each of eight (8) prescribed medications to R1, but did not immediately document their administration in the facility’s electronic Medication Administration Record (MAR) software, as Licensee had trained and expected S1 to do. R1 then went to eat breakfast in the facility’s first floor dining room. Around 8:30 AM, R1 approached Staff #2 (S2), who was assigned to the facility’s first floor, to request their medications. S2, not realizing that S1 had already given R1 their morning medications, gave R2 second doses for each of the same eight (8) medications. S2 subsequently realized an error had occurred and notified a facility nurse/manager, Staff #3 (S3). S3 observed R1 and took their blood pressure and pulse vital signs, which were in normal range. S3 timely contacted R1’s prescribing physician (PCP) for guidance and timely notified R1’s responsible person (RP) of the incident. S3 personally met with S1 and S2 to discuss the incident, then suspended S1 from medication pass duties. S3 performed formal/written coaching with S1 and retrained them (to include a written test), before reinstating R1 in medication pass duties a few days later. Progress notes show facility staff continued to provide increased observation to R1 for 72 hours following the incident, during which R1 continued to be free of any adverse reaction. A preponderance of evidence exists to show that during the above incidents, a documentation process error by Licensee’s staff (S1) resulted in R1 not receiving medications exactly as they were prescribed by their physician. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA issued one (1) Technical Violation (TV) regarding reporting requirements. LPA also provided Technical Assistance (TA) regarding medical assessments. An exit interview was conducted with Newton, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.