Incident investigation·April 16, 2025

On April 16, 2025, at 11:50 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding a medication error incident that occurred on 04/06/2025 when the resident (R1) was given medications of another resident. Upon arrival, the LPA was greeted by the Director of Health Services (DHS) Layana Santos. The LPA disclosed the purpose of the visit. The Executive Director (ED) Mark Baddas joined shortly after. LPA interviewed one (1) resident (R1) and three (3) staff members: Director of Health Services (DHS), Medication Technician (S1) and LVN Community Nurse (S2). R1 stated they were not bothered about the medication error, but this could happen was disturbing. R1 stated they always asked what medicines were given to them and thought more training could help to prevent such errors in the future. R1 confirmed they had no adverse side effects of the wrong medications given. S1 stated they felt the work overload caused the medication error and they were honest about the error and made sure the resident was doing ok and hence they followed the process of informing the nurse on duty. S1 stated they have been retrained on the med training on 04/09/2025. S2 stated that S1 came to them and informed about the medication error. S2 followed the procedure by taking resident vitals, told the doctor and the family. S2 checked on R1 every hour after that to make sure there are no side effects. DHS stated they were putting more checks in place, more frequent audits, added additional layers to make sure the med techs were properly dispensing medications. The facility followed the protocols by frequently checking R1 for change of condition, informed their doctor and the family member. DHS stated that the med tech had been given additional training to ensure that they do not make the medication error again. Continued on LIC809-C LPA reviewed R1’s Alert charting notes for 04/06/2025, which showed R1 was monitored for medication adverse reactions, if R1 was feeling dizziness. R1’s vitals were checked, noted and was put on hourly check for the day. R1’s vitals were noted with BP reading 137/75, Heart rate 70, Temperature 97.3 and Oxygen saturation levels at 97.3%. LPA reviewed R1’s Centrally Stored Medication and Destruction Records. LPA reviewed the message sent from R1’s PCP office regarding the follow up on the wrong medications given to R1. The nurse advised that wrong medications taken should not be harmful for R1 and advised the facility to report any changes in R1’s condition. No deficiencies were cited during today's visit. An exit interview was conducted with the Executive Director. A copy of this report was provided to the Executive Director, Mark Baddas, whose signature on this form confirms receipt of the report.