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32 | It is alleged that facility staff failed to properly administer and account for C1's prescribed medication, resulting in a medication error involving Magnesium Glycinate. On 03/29/2026, one 100 mg tablet of Magnesium Glycinate designated for the evening medication pass was unaccounted for. During staff interviews, S2 reported discovering the discrepancy while conducting the morning medication pass. S2 stated that C1 was prescribed a total of 400 mg of Magnesium Glycinate, administered through separate 100 mg bubble packs, and observed that one tablet intended for the evening medication pass was missing. S1 explained that it was possible the evening dose had been administered during the morning medication pass; however, staff were unable to determine with certainty whether the medication had been administered at the incorrect time or whether the evening dose had been missed altogether. S2 reported immediately notifying the on-call supervisor and explained that staff contacted the pharmacy for guidance. S1 stated that the pharmacy advised that the potential missed or incorrectly administered dose was not expected to result in adverse effects. Staff further reported that C1 was assessed and monitored throughout the remainder of the day, and no signs of distress or adverse symptoms were observed. S2 indicated that an incident report was completed, photographs of the medication bubble packs were obtained to document the discrepancy, and S1 reported additional medication training was provided following the incident. Staff also reported implementing corrective measures, including enhanced medication checks after each medication pass and reorganizing medication storage to better separate morning and evening medications.
During client interviews, C1 communicated through the use of a voice computer and stated that they could not recall the incident. C1 apologized for not being able to provide additional information and further stated that they liked living at the facility. LPA attempted to interview clients C2 through C4; however, due to cognitive limitations, they were unable to understand the questions being asked.
Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.
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