Incident investigation·May 24, 2022

Licensing Program Analyst (LPA), Jill Nakagawa arrived unannounced at Atria Covell Gardens for the purpose of following-up on an incident report that was self-reported to the Regional Office (RO). LPA was met by Administrator, Emily Venegas, and was granted access into the facility. CCL received an incident report reporting a medication error. The error occurred on 05/03/22 while S1 was dispensing medication, under the direction of S2. R1 was given the wrong prescribed medication during medication passing. R1's. Responsible party and prescribing doctor were notified of medication error and R1 taken to hospital for observation. R1 returned to facility with no adverse reactions. LPA obtained copy of the in-house incident report indicating a medication error. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 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. Exit interview was conducted with the Administrator and appeal rights were given.