Incident investigation·October 6, 2022

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Administrator Patrick Seawright. During today's visit LPA is following up on an incident report received at CCL on 9/9/22 involving resident (R1). Per incident report, on 9/8/22 it was discovered by staff that on 9/8/22 staff (S1) administered to resident (R1) an additional dose of Lamotrigine 25mg. S1 should have administered Lamortrigine 100mg one tablet by mouth instead of Lamortrigine 25mg one tablet by mouth in addition to Lamotrigine 100mg one tablet by mouth resulting in R1 received incorrect dosage. 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. S1 was placed on Administrative Leave pending an internal investigation by People's Care in accordance to their policy and procedures. During today’s visit LPA was provided with the Medication Assessment Record (MAR) for the month of September 2022 for C1 that reflects the said medication error. Per Administrator, S1 was aware of the medication changes but apparently got confused when was the start date after been told to start "next week" and did not make an attempt to contact Administrator for guidance. S1 was officially separated from the facility effective 10/5/22. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Civil penalties are issued today in the amount of $250 per repeated violation within 12 months. Exit interview was conducted with the Administrator and appeal rights were emailed to the Administrator.