Incident investigation·February 28, 2024

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management inspection and met with Resident Care Coordinator, Alka Ralh.. Facility recently reported that they had a medication error that resulted in a resident receiving the wrong medication. The error was noticed immediately and the proper reporting and monitoring was carried out. PCP and family were notified immediately. Facility transported resident to Emergency Room for observation. The client did not have any adverse effects. Executive Director has conducted trainings to all staff handling medications, and made changes to the medication process that provides additional oversight when medications are passed. No citations were issued at this time.