Incident investigation·February 16, 2022

On 02/16/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident submitted to CCLD on 01/29/2022. LPA spoke with Executive Director(ED), Mary Margaret Chappell and explained the purpose of the visit. Based on incident report, Staff #1 (S1) reported that a medication error had occurred on 01/24/2022. Methadone 2.5mg was due to be administered at 10:00PM and was administered in error at 8:00PM by Staff #2 (S2) after medication time was changed to 10:00PM resulting in the medication being administered twice. Based on documentation and interview, R1's primary care physician, Vitas hopsice agency, and R1's family member was notified on 01/24/2022. No adverse reaction or increased pain noted. Based on Staff #3 (S3), S2 was moved from Med Tech to care staff until additional medication training was completed. S3 stated, S2 no longer works at the facility. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview with Executive Director. Appeal rights and a copy of report given.