Incident investigation·April 27, 2024

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management for incident reported on 4/15/2024. This incident occurred on 4/14/2024 for medication error. LPA met with Executive Director (ED) Felicia Barkley. The report stated that facility Medication Technician (MT) gave resident (R1) the wrong medication on April 14, 2024 that happened in the morning during breakfast. R1s physician and family were notified. There was no side effects or adverse reactions reported or observed. Facility staff monitored R1 for any changes in condition after the incident. The frequency of monitoring by staff was every two hours. During today's visit, LPA Partoza interviewed ED. ED stated she was notified by the Resident Service director who was notified by the staff regarding the medication error and upon investigation it was discovered that the medication error was caused by a human error. ED stated that MT was given a final warning. ED will email LPA Partoza the requested documents from ED a copy of S1s training records and the length of observation for R1. This case management will be kept open pending investigation. Exit interview conducted with ED Felicia Barkley and a copy of this report provided.