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25 | On 01/28/21 at 1:10PM, LPA D Panlilio conducted a case management tele-visit with Health Services Director (S1) to discuss the incident reported to CCLD on 01/15/21 wherein a staff in Med Tech training (S2) switched 14 tablets of Norco for ibuprofen 800 mg. on 01/10/21. Due to COVID-19 shelter in place order, S1 was not physically available to sign this report.
S1 stated that S2 was hired on 12/30/20 as an on call Med Tech in training program. On coming NOC medication care manager (S4) noted the change in tablet size and reported the incident to the Health Services Director (S1).Facility conducted an internal investigation and interviewed staff responsible for counting and dispensing of centrally stored and controlled scheduled medications.
Per Hiring Director (S3), S2 was removed from the medication assistance program on 01/10. She left the facility the same day and has not returned since. Per S3, if S2 does not show up for work in 2 weeks, they will proceed with termination. Medication caregivers and Wellness nurses underwent a refresher course on procedures and policies for Centrally stored medication, Controlled scheduled medication protocol and medication key cart control policies on 01/12/21. Med care managers were also written up for not following procedures on medication administration.
No deficiencies observed or cited during this tele- visit. Exit interview conducted and a copy of this report provided via email. |