Incident investigation·May 21, 2025

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPA met with and stated the purpose of the visit. On May 20, 2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on May 13, 2025. The incident report states: "on 5/13/25, during medication reconciliation, it was identified that the resident continued to receive Medication M1, 50 mg despite a physicians order on 4/23/25 to discontinue the 50mg does and initiate M1 25 mg instead. From 4/23/25 to 5/13/25, the resident erroneously continued to receive the 50 mg dose. this discrepancy was identified by the hospice nurse. " On May 20, 2025, LPA Marrufo interviewed ADM. ADM stated R1's medication was changed to half dose instead of a full one and they did not catch that the order was changed. ADM stated an in-service was provided to staff. On May 21, 2025, LPA Monter interviewed Resident Care Coordinator. (RCC). RCC stated the residents physicians order on 4/23/25, instructed a change to the residents dosage. RCC stated the med techs are supposed to send this update to the pharmacy to update those changes. RCC stated this issue was noticed by the hospice nurse on May 13, and update that same day. A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with Administrator Meghian Geul and a copy of this report was provided. Appeal rights were also provided.