Incident investigation·July 7, 2022

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Licensee Patrick Seawright. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet. During today's visit LPA is following up on an incident report received at CCL on 6/6/22 involving resident (R1). Per incident report, on 6/3/22 at around 5:00pm it was discovered by staff that on 6/2/22 staff (S1) administered to resident (R1) an additional dose of Lamotrigine 25mg. S1 should have administered Lamortrigine 25mg two tablets by mouth instead of three tablets by mouth. Upon the discovery about the incorrect dosage that was provided to resident. R1 was monitored for any adverse reaction or change in condition observed. Responsible parties including their Physician, NBRC and CCL were notified. As a preventive plan, the Administrator will discipline S1 according to facility policy and procedure regarding medication error and S1 will be retrained on the Medication Administration Policy and Procedure then will demonstrate the appropriate skill and knowledge to the Administrator prior to being allowed to administer medications to residents in care. During today’s visit LPA was provided with facility training records for S1 dated 6/6/22 between 1:00pm to 2:00pm. Training subjects include medication management, medication storage requirements and check, medication 15min check, medication errors and reporting, medication competency test and medication certification practicum checklist to remind staff to follow physician’s directions and assist clients with their medications as prescribed. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.