Incident investigation·October 19, 2023

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit. This case management visit was regarding an incident which occurred on 9/25/2023. LPA Rai met with Administrator (ADM) Flavio Silva and stated the purpose of the visit. Per report, facility medication technician (S4) did not administer medication to resident (R1) resulting in missing a dose of medication prescribed by R1's physician. The R1's responsible party was contacted right away and R1's primary care physician was notified. Facility staff was advised to monitor R1 for any change of condition. During today's visit, LPA Rai interview with ADM, who was notified by another staff member of the medication error and upon investigation it was discovered the medication error did occur based on electronic Medication Administration Record (eMAR) and ADM observed the missed dose still within the medication package. S4 was suspended and later terminated. ADM stated R1 was okay after the reported incident. LPA Rai interviewed S1-S3. LPA Rai obtained a copy of S2-S3's most recent completed training course and resident roster. ADM will email LPA Rai copy of S2-S4's training records and updated LIC 500. This case management will be kept open pending investigation. Exit interview conducted with Administrator (ADM) Flavio Silva and a copy of this report provided.