Incident investigation·April 23, 2025

On April 23, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 04/17/2025 when the resident (R1) was administered the incorrect medicine by a staff member. Upon arrival, LPA met with the Chief Operating Officer (COO) Elvyra Abare and Assistant Administrator (AAD), Beth Shirley. The LPA disclosed the purpose of the visit. LPA interviewed three (3) staff members: S1, S2, and COO. LPA interviewed S1 over the phone. S1 stated that on 04/17/2025, they had received a call from staff (S2) reporting a medication error. S2 had administered one of the Assisted Living (AL) resident’s morning medications to Independent Living (IL) resident R1. According to S1, S2 was conducting a medication pass when the phone rang. S2 grabbed a medication cup from the top of the med cart and administered the medications to R1. IL residents who are on medication management typically go down to AL to receive their medications. After completing the phone call, S2 realized that R1’s actual medications were still on the cart, but R1 had already left. R1, R1’s family member, and R1’s primary care physician (PCP) were informed about the medication error. R1 was offered the option to return to AL for monitoring. The PCP recommended that staff monitor R1 and continue with their regular medications. The COO stated that the nurse responsible for the medication error would receive education and training. The plan was to assign the nurse a Relias training module, including a reminder on medication administration protocols and a quiz. Continue on LIC809-C The COO emphasized that, fortunately, R1 did not experience any adverse effects or changes in condition. Staff continued to monitor R1 every hour for the first 24 hours and extended the monitoring to 72 hours. S2 stated that around 8:20 AM on 04/17/2025, R1 came to AL to receive their medication. At the same time, another AL resident was approaching quickly on a scooter requesting their medication, and the telephone rang. S2 answered the phone and, while distracted, handed the wrong medication cup to R1, who took the medication and left. A few minutes later, S2 realized that R1’s medications were still on the cart and that the wrong medications had been given. S2 checked whether R1 had any known allergies to the administered medication and then went to R1’s room to inform them of the error and the need for monitoring. S2 then returned to the nursing station and notified S1 of the incident. S2 also contacted R1’s PCP office, and at approximately 1:50 PM, the medical assistant advised to continue regular medications and to withhold one specific medication only if R1’s blood pressure was below 130/80. S2 confirmed that R1 did not experience any adverse effects and was doing well. S2 endorsed the situation to the incoming evening shift and instructed them to continue monitoring R1 and to check blood pressure before administering medications. S2 stated they learned from the incident and acknowledged the importance of not answering phone calls during medication passes unless it is an emergency. Although S2 had not yet received new training following the incident, they mentioned having worked at the facility for 17 years and had always maintained focus on their responsibilities. S2 also shared that R1 had expressed understanding, stating, "Everyone makes mistakes. We are all human and not perfect." AAD called to check if the resident (R1) is willing to talk to the LPA about the medication incident that happened last week, but the resident stated that it’s not necessary for them to talk to the LPA LPA reviewed R1’s progress notes for 04/17/2025, which documented the medication error in detail. The notes indicated that R1 had been offered the option to stay in an AL room for monitoring, but R1 declined. Staff began taking R1’s blood pressure readings hourly starting at 9:30 AM. At 1:30 PM, R1 left the facility with a family member for a pre-scheduled appointment with their cardiologist. After 3:30 PM on 04/17/2025, R1 resumed their regular medications. Continue on LIC809-C LPA also reviewed R1’s Centrally Stored Medication and Destruction Records, the Medication Administration Record (MAR), and obtained a list of the incorrect medications that had been administered. LPA requested AAD to submit proof of S2’s training and continuing education. No deficiencies were cited during today's visit. An exit interview was conducted with the Assistant Administrator. A copy of this report was provided to the Assistant Administrator, Beth Shirley, whose signature on this form confirms receipt of the report.