Incident investigation·October 2, 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 Executive Director Austin Irwin. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 09/18/2023). According to the LIC624, during the evening of 09/07/2023, an error by Staff #1 (S1) led to Resident #1 (R1) not receiving one (1) of their medicines as it was prescribed. [See LIC 811 Confidential Names List for a description of 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 safe, alert, and participating in a recreational activity. LPA also interviewed pertinent staff and reviewed relevant care records. Per their latest LIC602 Physician’s Report (dated 08/31/2023), R1 was diagnosed with Mild Cognitive Impairment and required staff assistance with taking their prescribed medications. Manager interview confirmed this. Staff interviews, corroborated by records, showed: On 09/07/2023, S1 gave R1 two (2) tablets, instead of the prescribed one (1) tablet, for one of their medications. Licensee’s staff timely notified R1’s prescribing physician (PCP) of the error, followed PCP instructions, and provided increased observation of R1. The medication error did not result in any adverse health consequence for R1. Personnel and training records showed: Following the incident, Licensee undertook individual written corrective action and retraining with S1. On 09/21/2023, Licensee also retrained its larger medication technician team on accurate medication pass procedures. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 a medication as it was prescribed. The incident did not result in injury or 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 one (1) Technical Violation (TV) regarding Reporting Requirements. An exit interview was conducted with Irwin, 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.