Incident investigation·April 25, 2024

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a Case Management visit and met with Administrator, Gregory Becker. The purpose of the visit is to follow-up on an incident report the Department received regarding medication error at the facility which occurred on 04/9/2024. On 4/10/2024, the Department received an incident report regarding a medication error for resident (R1) which resulted in R1 taking additional dosage of medication which exceeded physician's order. Based on interview with ADM and Resident Service Director (RSD), the facility manages R1's medication and R1's family brought and left medication in R1's room without the knowledge of facility staff. The facility's medication technician (Med-Tech) administered the medication as per doctor's orders. R1 administered two doses of medication on her own with the medication bottle available in the room. During visit, LPA Rai reviewed R1's Physician's Report dated 3/22/2024, which states R1 has Dementia and is not able to administer own prescription and PRN medications and is not able to store own medication. LPA Rai requests that Administrator, Gregory Becker submit a Plan of Action to address the ongoing staff training and mitigations that will be put in place to prevent future medication errors. No deficiencies were cited at this time as per California Code of Regulations Title 22. An Advisory Note was issued, please see LIC 9102. This report was reviewed with Administrator, Gregory Becker and a copy of this report was provided.