Incident investigation·July 31, 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 Receptionist Angelina Sandoval. LPA then met with Executive Director Emily DeLaBarre. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 06/20/2023. According to the LIC624, during the afternoon of 06/18/2023, 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 and welfare check on R1, finding that they were alert, talkative, safe, and able to ambulate without difficulty. LPA also reviewed pertinent facility and hospital records and interviewed relevant staff. Per their latest LIC602 Physician’s Report (dated 03/16/2023), R1 was diagnosed with Dementia and required staff assistance with storing and taking their prescribed medications. Due to their baseline memory loss, R1 was not able to recall any details about the incident. Staff interview and records revealed: During the incident, S1 dispensed medications for R1 and R2 into two separate cups, one for each resident. While S1 looked away, R1 reached into the drawer of S1’s medication cart, which is required to be locked when not actively used and supervised. R1 grabbed the cup of pills which were intended for R2. By the time S1 realized this happened, R1 had ingested multiple tablets not prescribed to them. After this incident, R1 presented no adverse health symptoms, but facility staff still called 911 as a precaution. Paramedics gave R1 activated charcoal and transported them to the hospital for observation. R1 discharged back to the facility the next day, with no indication of any injury or illness. Facility staff provided increased observation to R1 for another 24 hours after their return to the facility, and R1 continued to feel well. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Also, S1 timely reported the incident to facility management, who timely phoned C1’s physician’s office and C1’s responsible person. Licensee immediately removed S1 from medication pass duties, retraining them (to include written test with skills validation) before reinstating S1 in those tasks. On 06/23/2023, Licensee also retrained its larger direct care team on accurate medication pass procedures, to include written test with skills validation. The above training included teaching staff to not “pre-pour” medications, but to instead fill only one cup with pills at a time, before moving on to the next resident. The medication errors which affected R1 on the afternoon 06/18/2023 did not prevent R2 from receiving their respective prescribed medications on that date. A preponderance of evidence exists to show that during the incident in question, License’s staff (S1) did not keep medications (which were required to be centrally stored) from being directly accessible to clients. This lapse was material to the incident occurring, but 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). LPA also issued one (1) Technical Violation (TV) regarding reporting requirements. An exit interview was conducted with DeLaBarre, 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.