Incident investigation·September 8, 2023

LPA 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 Adrian Gullien and Resident Services Director Monica Maldonado. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/18/2023). According to the LIC624: during the morning of 08/17/2023, 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, reviewed pertinent care records, and interviewed relevant staff. Records and staff interviews showed: R1 relied on License’s staff for help with storing and taking their prescribed medications. Licensee taught its medication technicians to use plastic holding/transport containers during medication pass. These containers were subdivided, with each partition being labeled with the resident’s full name, room number, and profile photograph. During the incident, S1 chose to not use this labeled container(s), which contributed to them mistakenly giving R2’s medicines to R1. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Licensee’s staff timely notified R1’s primary care physician (PCP), hospice agency, and responsible person. Licensee adhered to PCP instructions, which included measuring R1’s blood sugar and blood pressure over the next twelve (12) hours. R1’s initial “sleepiness” subsided after a few hours; they did not suffer any other negative health consequence from the incident. The medication errors which affected R1 on morning of 08/17/2023 did not prevent R2 from receiving their respective prescribed medications on that date. Licensee immediately removed S1 from medication pass duties and had them undergo retraining (to include skills validation). A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 medications as they were prescribed. The incident did not result in injury or serious illness to R1. 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 also issued two (2) Technical Violations (TV) regarding reporting requirements. An exit interview was conducted with Gullien, to whom a copy of this report, the LIC 809-D, the LIC9102-TV pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.