Incident investigation·January 23, 2025

On January 23, 2025 at approximately 12:00 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at An Osprey Retreat for the purpose of conducting a Case Management-Incident Inspection. LPA met with Administrator, Laurie Schlottman and was granted access into the facility. During the incident, the medication was administered to the wrong resident in care (See LIC 9102-Technical Violation) . Staff immediately called the Administrator. Administrator instructed staff to contact Poison Control. Instructions were given by Poison Control. Administrator reported this incident to the Primary Care Physician via facsimile and the Regional Center placement agency. LPA educated the Administrator on the importance of ensuring that ALL medications are dispensed as outlined in the residents physician orders and as outlined in Title 22 Regulations. Administrator reported that staff that dispensed the wrong medication will be going through additional training. LPA also advised that if this medication error happens again, a citation will be issued. LPA toured the facility and made observations. No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was signed and given to the Administrator.