Incident investigation·August 9, 2024

At approximately 12:15pm, Licensing Program Analyst (LPA) Christi Coppo arrived announced to conduct a case management visit in regards to an incident report submitted to CCL on 7/19/2024. On 7/19/2024 the facility submitted to CCL an Incident report indicating a medication error had occurred at the facility. On 7/16/2024, facility began helping R1 with self-administration of medications. Incident report explains that at approximately 1:30am on 7/18/2024 resident (R1) reported to NOC shift caregiver (S1) needing their PRN pain medication. R1 has a physician's order for PRN Tramadol and scheduled Gabapentin. At this time, a Medication Technician (Med Tech) was not on schedule for the NOC shift, so S1 located the medication from the medication cart and provided it to R1. At approximately 6:00am, S1 reported to the oncoming day shift Med Tech (S2) that they had provided R1 with their PRN Tramadol and their scheduled Gabapentin. S2 immediately report the incident to Health and Wellness Director (HWD). HWD then notified R1's responsible party and advised them of the incident. HWD also contacted Kaiser help line and left a message for R1's doctor. HWD left message for doctor and also sent over a fax indicating R1's medication error and inquiring as to a possible change in medication timing. Per R1's responsible party, the doctor was supposed to change the Gabapentin prescription from being scheduled every 4 hours to every 6 hours. HWD requested R1's responsible party to also follow up with doctor as HWD had not received a response back or call back from R1's doctor. R1 did not exhibit any adverse reactions from the 1:30am dose of the PRN Tramadol and Gabapentin. Per R1's responsible party, the resident was believed to be self-administering the Gabapentin during these early morning hours prior to facility's start of helping R1 with their medication. LPA confirmed R1 still has not exhibited any adverse reactions stemming from medication error. Continued on 809C... Continued form 809... Per LPA interview with HWD, S1 was terminated on 7/19/2024. Facility did not place R1 on 72 hour monitoring because the medications given were within the parameters of the physician's orders. Facility change their scheduling of Med Techs in response to this incident. Facility now has a Med Tech assigned to each shift, including NOC shift. If for any reason a Med Tech is not available to work their shift, then HWD is committed to covering the needed shift in order to ensure that someone is attending to medications 24 hours per day. Facility conducted training with staff caregivers and had them sign a form indicating that they are not to administer medication for any resident, at any time, for any reason. In addition to the training conducted with caregivers, facility also conducted training with staff Med Techs and had them sign a form indicating that they are aware of the medication policy and procedures. As an extra precaution, HWD is currently in the process of redesigning medication room for improved safety and to mitigate medication errors. HWD provided training logs and acknowledgements to LPA during case management. Additionally, HWD conduct audit of medication counts to verify all medications administered match current medication counts.