Incident investigation·December 1, 2022

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Interim Executive Director Donna Daniel-Herr. The purpose of the visit was to investigate a medication error reported by the facility via LIC624 Unusual Incident Report that was reported to the Department on 11/16/2022. The incident occurred on 11/10/2022 and involved staff S1 and S2 discovering during a medication audit occurring during a shift transition that resident R1's medication had gone missing. During visit, LPA Marrufo interviewed staff S3 and Interim Executive Director Donna Daniel-Herr. LPA reviewed facility records, including R1's Centrally Stored Medication Log (CSML) and Medication Administration Record (MAR), Invoice with company contracted to pick up destroyed medications from the facility for further disposal, Memorandum dated 11/14/2022 and addressed to all Assisted Living Medical Technicians, Attendance Roster for Staff Training on Missing Narcotics dated 11/14-18/2022, and Weekly Controlled Narcotic Shift Count Log, and Disposal of Medications Policy. R1's CSML states that the missing narcotic was logged into the record on 10/14/2022 and is to be administered as needed. R1's MAR indicates the medication was never administered to R1. S3 stated during interview that the procedure for destroying narcotic medications is to pour them into a destruction bottle and have two Medication Technicians sign and document the destruction process in the residents CSML. Then, the medications are picked up by the medication destruction company. S3 stated the facility procedure is to have two staff audit the medications per each change in shift and attest to the medication audit in a log. LPA Marrufo obtained a copy of the Weekly Controlled Narcotic Shift Count Log. S3 stated that facility staff did not know what happened to R1's missing medication. See LIC809-C for more information. The facility Memo states that for each shift, the oncoming Medication Technician assumed responsibility for all narcotics and attests that the count is correct. It states both the incoming and outgoing Medication Technician must visually confirm and sign off on the count of medications at the change of each shift. No deficiencies were cited at this time as per California Code of Regulations Title 22. An Advisory Note was issued. See LIC9102 for more information. This report was reviewed with Interim Executive Director Donna Daniel-Herr and a copy of the report was provided.