Incident investigation·August 1, 2023

Licensing Program Analyst (LPA) Esther Cotez conducted an unannounced Case Management – Incident inspection pertaining to a self-reported Special Incident Report (SIR) received on 07/31/2023. The LPA met with Executive Director Gary Lee at 09:25 AM and informed them the reason for the visit. The self-reported SIR pertains to a medication error that occurred on 07/27/2023. Upon further file review the LPA received various self-reported SIRs regarding medication errors involving various residents for the months of April (4), June (1) and July (11), as a reoccurring issue. Medications errors include missed medications and high blood sugars for various residents. On 4/25/2023 the LPA spoke to Executive Director Gary, and they stated that all MedTech’s were going to complete in service training checking that medications were being passed all three times. The ED was not able to produce verification of the in- service training. During today's inspection, at 10:12 a.m. the LPA obtained pertinent documents and reviewed the following Special Incident Reports with Executive Director Gary and Assistant Administrator Leticia Hernandez: 07/15/2023, 7/23-7/25/23: Resident 1 (R1) Missed Medication 07/17/2023, 7/22/2023: Resident 2 (R2) Missed Medication 7/22/2023 Resident 3 (R3) Missed Medication 7/23/2023 Resident 4 (R4) High Blood Sugar 7/24/2023, 7/26-27/23 Resident 5 (R5) High Blood Sugar 7/27/2023 Resident 6 (R6) Missed Medications REPORT WILL CONTINUE ON LIC809-C Executive Director Gary indicated that missed medications errors occurred due to staff not paying attention, and possibly due to residents having too many medications and staff getting confused. The LPA advised the ED, that staff should be trained on handling residents medications. He continued to state that even though different Med technicians have been making errors, a lot of the missed medications have been made by their new staff (S1). The ED stated that they hired S1 due to having a lot of experience, but he thinks S1 brought a lot of bad habits and will be requiring more in service training on medication as well as shadowing. Both the ED and Assistant Administrator Leticia Hernandez stated that staff is not trained on how to care for residents with Diabetes. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued to Administrator.