Incident investigation·December 20, 2022

On December 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an incident that was reported on December 7, 2022. LPA met with Resident Care Director (RCD) Ed Dewitt, and explained the purpose of the visit. The Licensee reported on November 30, 2022, narcotics were missing from the lock box. The RCD immediately conducted an investigation at the facility. According to the Hospice Nurse, on 11/30/22, the nurse signed for the destruction, however did not observe the facility med-tech destroy the medications. On 12/1/22, the RCD and the Administrator spoke to the med-tech and the med-tech admitted that he/she had the hospice nurse sign for destruction without the hospice nurse being present. In addition, the med-tech indicated he/she put the narcotics in a container in the Wellness Center, however there was no container present in the room. According to the RCD, the Administrator or the RCD are the only people who destroys narcotics with another licensed nurse and the med-tech involved did not get the RCD's authorization to destroy medications. During the visit, LPA spoke to the RCD. According to RCD, the med-tech involved was terminated on 12/1/2022 and the police department was notified. An in-service training was conducted regarding medication destruction on 12/3/2022 and a copy of the training sheet was provided. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Resident Care Director, Ed Dewitt and a copy is provided with appeals rights.