Incident investigation·February 29, 2024

Licensing Program Analyst (LPA) Cuadra arrived unannounced at facility for the purpose of conducting a Case Management- incident inspection regarding a medication error. LPA met with Administrator Toni Pump. LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 01/10/2024 of a medication error. The error occurred on 1/9/2024 when staff (S1) was performing a spot check of medications of resident (R1), there was a discrepancy observed by S1 with medication named hydromorphone 4mg, which were not logged into the Centrally Stored Medication Log, then S1 notified responsible parties including CCL about the medication error. Per Administrator, R1's responsible party is responsible to bring the medication over to the facility, staff used to receive any amount of medications and if it was stapled they would not count the medication. S1 does not recall if the medication brought by the responsible party was stapled or not, because it was about 30 days ago. Administrator provided LPA with the Centrally Stored Medication Log for the month of January 2024 and Medication Administration Records that indicates that R1 was assisted with their medication as prescribed by their Physician. There is a new procedure implemented where all staff must count the medications every time that responsible parties bring medications over for residents, unless that they are stapled coming directly from the pharmacy. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with the Administrator and copy of this report as well as appeal of rights were provided.