Follow-up·October 12, 2022

On 10/12/22, Licensed Program Analyst (LPA) R. Campbell arrived at Brookdale Kettlemen at approximately 1:00 pm to conduct a case management visit regarding an incident submitted to CCLD on 07/17/22. LPA spoke with Med Tech Delma De la Pena and explained the purpose of the visit. Based on incident report, Med Tech #1(M1) reported that a medication error occurred on 07/17/22 . During change of shift, M1 was counting narcotics and realized Resident #1(R1) had not been given a full dose. R1 was to receive a 7.5mg of Methadone orally at 9 am but instead was only given 5 mg. R1 did not have any signs of distress or complaints of pain. R1's physician and family members were made aware of incident. Also on 08/15/22 facility reported that Resident #2 (R2) missed her dosage of Ativan and Tramadol as well and a dose of Tramadol 50 mg was missing for Resident #3(R3) . Based on a review of R1’s incident that occurred on 07/17/22, R2’s incident report from 08/15/22, R3's incident report from 08/20/22 and their Medication Logs, medication was not provided or was provided incorrectly in error. 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 was given.