August 4, 2022
What Happened
Case Management incident investigation revealed medication administration error on 7/28/22: child C1 received medication prescribed for C2 due to similar-looking containers with spilled medication covering label. Error discovered immediately, parents and physician notified; child remained in care without adverse effects. Type A citation issued.
Observations
- Wrong child administered medication (C1 received C2's medication)
- Similar-looking medication containers contributed to error
- Spill covering medication label prevented identification
- Medication storage/identification system inadequate
Inspector Focus
Citations Issued
101226 Health-Related Services (e) In centers where the licensee chooses to handle medications: (3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This requirement was not met, as evidenced by: Based on interviews and reports Child 1 (C1) was administered medication that was not prescribed to them, and was instead prescribed for another child (C2). This poses an immidiate health and safety risk to children in care.
What does this citation mean? →Data sourced from California Department of Social Services (CDSS) public records. Updated weekly. If you believe any information is inaccurate, report it here.