Incident investigation·June 6, 2022

On 06/06/2022, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident submitted to CCLD on 04/05/2022. LPA spoke with Health and Wellness Director, Gretchen Monares and explained the purpose of the visit. Based on incident report, Staff #1 (S1) reported that a medication error had occurred on 04/05/2022. Staff #2 (S2) was counting narcotics/anti-biotics for end of shift when S2 told Staff #3 (S3) she had not given Resident #1 (R1) dose of Linezolide. S2 failed to look at the antibiotic count shet and proceeded to give R1 a dose of Linezolide. As S2 proceeded to sign out the medication in the count sheet, he noted S1 had already signed out dose to R1. Based on incident report, R1 received 2 doses of Linezolide. R1 did not have any signs of distress or complaints of pain. R1's physican and family members was made aware of incident. 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 Health and Wellness Director. Appeal rights and a copy of report given.