Incident investigation·December 5, 2023

On 12/04/2023, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to this facility to conduct a case management visit. LPA met with Administrator, Rikki Perezchica and explained the purpose of the visit. Current Census was 177. The purpose of this visit was to follow up on a Medication Error incident Report on 10/26/23 and several reports of falls that occurred between 11/04/23 and 11/07/23. LPA Campbell interviewed the Administrator and Medical Technician LPA Campbell conducted interviews and reviewed facility documentation. The Unusual Incident Report received by the department on 10/26/23 states that a resident received a medication in error. The resident was later admitted to the hospital that same night due to severe constipation. Though it is unknown if this was due to the medication error. LPA Campbell reviewed the residents MAR for the date of the incident. It was learned that the Medication Technician admitted that the error was due to her inattention. An internal investigation was conducted and the MT involved underwent procedural retraining that included the 6 Rights of Medication, shadowing and a Medication Management Competency Quiz. The MT has not experienced further medication errors per the administrator. The Unusual Incident Report received by the department between 11/04/23 and 11/07/23 involved several resident falls. LPA Campbell reviewed the incident reports, progress notes and service plans for the residents involved. Of the falls recorded, there was no common denominator. Residents fell due to a refusal to follow their care, because they were in need of a change in their care plan or because the resident experienced a one time fall after tripping. It was learned that the facility provided all residents a fall risk re-evaluation according to the facility Fall Policy and adjustments in their care plans were made as needed. Based on the information gathered during today's visit. No deficiencies are being cited. An exit interview was conducted and a copy of this report was provided to the facility.