Incident investigation·March 27, 2025

On March 27, 2025, at 8:55 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 03/19/2025 when the resident (R1) was given a PRN as needed medication by mistake. Upon arrival, the LPA was greeted by the Health and Wellness Director (HWD), Patricia Oliver and Business Office Director (BOD), Diana Smith. The LPA disclosed the purpose of the visit. LPA interviewed one (1) resident (R1) and four (4) staff members: Executive Director (ED), Health and Wellness Director (HWD), Medication Technician (S1) and LVN Community Nurse (S2). HWD stated that on 03/19/2025, R1 was given ‘Labetalol,’ a medication that was ordered as needed. R1 knew their medications well and told the Med Tech that they were not supposed to have the medication unless there was a specific need for it and R1 said they should not have received this medication. HWD stated that S1 did not read or recognize the medication order on the QMAR as an as-needed order, and R1 was concerned about having received the wrong medication. HWD stated that R1 had been diagnosed with Parkinson’s and was receiving care in the elite care unit following their return from the hospital for a UTI. R1 had been alert and oriented. HWD mentioned that S1 had reached out to S2, who then performed a bedside assessment of R1. S2 called and faxed R1’s PCP regarding the medication error and received instructions from the PCP on the care plan in response to the error. HWD stated that the facility held a care conference call with R1’s family to explain how the medication error occurred and what actions the facility was taking to prevent similar errors in the future. Continued on LIC-809C ED stated that S1 had administered ‘Labetalol,’ a PRN medication, thinking it was a routine medication. The medication was supposed to be given only as needed, after checking the blood pressure and confirming it met certain parameters. R1 took the medication and asked S1 which medications had been given. S1 and R1 both realized at the same time that the wrong medication had been administered. R1 remained stable and experienced with no side effects. S2 reached out to R1’s PCP regarding the medication error. ED stated that they had conducted a Zoom meeting with R1’s family on the same day. ED stated that S1 had been working at the facility for a long time and was a very good med tech who cared deeply for the residents. S1 stated that on 03/19/2025, they had given R1 their morning medications at 8:30 AM. The ‘Labetalol’ PRN medication had appeared as a routine medication in the QMAR. The medication was supposed to be administered only if R1’s blood pressure exceeded the specified parameter. S1 stated that R1’s blood pressure had been below that parameter, but they had still administered the medication. They acknowledged it was their error. After checking the QMAR, they realized the parameter did not support giving the medication. S1 stated that R1 had asked for the names of the medications given to them but had not said anything about why the ‘Labetalol’ had been administered. S2 stated that the ‘Labetalol’ medication had been set as a routine medication in the QMAR but included a parameter indicating it should be given only if the blood pressure exceeded a certain threshold. R1 had moved to the elite care unit on 03/13/2025 or 03/14/2025. S2 stated that S1 had called them, and S2 had informed R1 that the ‘Labetalol’ had been administered in error. S2 stated that R1 appeared anxious but not visibly upset. S2 performed a blood pressure reading and asked R1 how they were feeling. S2 called R1’s PCP, reported the medication error, and coordinated with the PCP regarding R1’s care plan following the error. R1 stated that they were aware of the medication error involving ‘Labetalol’ and knew which medications they were supposed to be taking, as they always asked. R1 stated that the facility had categorized ‘Labetalol’ as a routine medication. R1 also stated that some individuals at the facility did not know the purpose behind certain medications. These individuals were new and only knew the quantity of medications to administer. R1 stated that their blood pressure was highly variable and that they had other conditions that put them at high risk for stroke, making such medication errors potentially life-threatening. R1 stated that they could not remember how they felt on the specific day the ‘Labetalol’ was given in error; they generally felt tired and lethargic but had no recollection of that particular day. Continued on LIC809-C R1 stated that similar errors had occurred in the past at the Commons. Staff did not understand the doctor’s order and used their own interpretation instead of contacting the doctor for clarification, which was not how the doctor intended the medication to be used. R1 stated that they felt additional staff training, increased supervision, more managerial oversight, and frequent evaluations of medication administration practices at Commons could help prevent such errors. LPA reviewed R1’s hospital discharge notice, dated 03/13/2025, which indicated to administer one ‘Labetalol’ as needed for SBP >170 or DBP >105. LPA reviewed R1’s vital signs record. The blood pressure reading taken at 8:43 AM on 03/19/2025 showed reading written as 146/90. LPA reviewed R1's Medication Administration Record (MAR). The 'Labetalol' 100 MG medication was listed as needed for SBP>170, DBP>105. LPA reviewed R1's Centrally Stored Medication Records, which showed Labetalol' medication listed with instructions "Take 1/2 tablet (50 MG) as needed SBP>170, DBP>105. LPA reviewed the faxed note sent to R1’s doctor indicating that a medication error had occurred. R1 had been given ‘Labetalol’ 50 mg despite a blood pressure reading of 146/90. A deficiency was cited based on LPA observations, record reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Business Office Director. A copy of this report and appeal rights were discussed and provided to the Business Office Director, Diana Smith, whose signature on this form confirms receipt of these documents.