Incident investigation·May 23, 2024

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Gregory Case. 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 05/17/2024. [See LIC 811 Confidential Names List for a description of residents]. Per the self-reported document, on 05/10/24 during the evening shift, nine (9) residents missed their medications due to staff inability to meet the two hour time frame of medication assistance. During today’s visit, LPA performed a brief welfare check on residents, finding no safety concerns. LPA interviewed Executive Director Gregory Case and Regional Clinical Specialist Joanne Gomez regarding the incident. A facility internal investigation was conducted and it was concluded that the error occurred due to the facility experiencing a shortage of staff. Immediately after the incident, all of the residents’ Primary Care Physicians and Responsible Parties were informed. No resident experienced adverse effects from the error. The facility implemented a plan to hire extra Med Tech staff as back-up. The facility also conducted an in-service training on proper medication management procedures for all staff responsible for handling medications. 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 Gregory, whose signature below confirms receipt of a copy of this report, the LIC811 and the Licensee Rights (LIC 9058 01/16).