Incident investigation·October 10, 2022

On October 10, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on October 6, 2022. LPA met with Executive Director, Siobhan Surraco and explained the purpose of the visit. The Licensee reported on September 18, 2022, Resident #1 (R1) and Resident #2 (R2) missed a dosage of their standing orders for their medications due to Med-Tech error. According to the Licensee, the error was discovered the same day during the change of shift. In addition, it was indicated that the Med-Tech reported he/she made a mistake and was rushing. During the visit, LPA spoke to Executive Director and Resident Care Director, Ed Dewitt and reviewed R1's and R2's files. Based on file reviewed, R1 has a diagnosis of cognitive impairment and diabetes. R2 has a diagnosis of Escherichia coli with muscle weakness. According to the Resident Care Director, the missed medications were prescriptions ordered by both resident's physicians. Based on record reviewed and staff interviews, the facility Med-Tech missed a dosage of R1 and R2's prescribed medication which were ordered by their physician. Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed. This report was reviewed and discussed with Executive Director, Siobhan Surraco, and a copy is provided. Appeals Rights were given.