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25 | Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Sam El Rabaa.
Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 01/29/2024). According to the LIC624, on 01/21/2024, it was observed that Resident #1 (R1) had three (3) transdermal medication patches on their skin/body simultaneously, instead of just the prescribed one (1) patch at a time. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. This incident did not result in any adverse health consequence for R1.
During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe and at their baseline level of functioning. LPA interviewed pertinent facility staff and an outside witness. LPA collected copies of and reviewed pertinent care and personnel records. LPA also inspected the box and pharmacy label for R1’s medicated patch, and reviewed the published usage guidance from the manufacturer for said patch.
Per their latest LIC602 Physician’s Report (dated 09/21/2022), R1 was diagnosed with Dementia and Parkinson’s Disease. R1’s doctor determined that R1 was “confused/disoriented,” required staff assistance with taking their prescribed medications, and required staff assistance with bathing and dressing, among other personal care needs. Manager interview corroborated these points. LPA was unable to qualify R1 as a reliable historian/interviewee for this case, due to R1’s baseline cognitive impairment.
[CONTINUED ON LIC 809-C, 1 of 2] |
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Records and interviews showed that the prescribed dosage for R1’s transdermal Rivastigmine patch was 9.5 mg per 24-hour release period. According to the pharmacy label, staff were instructed to “Place 1 patch on [R1’s] skin daily.” According to the prescribing order detailed in R1’s Medication Administrator Record (MAR), staff were instructed to “Apply 1 patch topically daily…to upper body, chest, arm or back…rotating sites each day.”
Records and interviews showed: There was one morning in late January 2024 when R1 was witnessed with three (3) Rivastigmine patches on their skin at the same time (there was disagreement about whether the discovery occurred on 01/21/2024 or on 01/22/2024). Upon recognition of the error, Licensee timely notified R1’s prescribing physician and responsible person (RP). R1 did not display adverse health symptoms. On 01/24/2024, Licensee performed written corrective action and retrained Staff #1 (S1), who it determined was involved with the error. [Per the MAR for R1: Staff #2 (S2) applied the patch to R1’s skin on 01/19/2024. S1 applied said patch to R1 on 01/20/2024, 01/21/2024, and 01/22/2024.] As of the date of LPA’s site visit, S2 was no longer employed at the facility.
According to the original drug manufacturer’s box which R1’s patches arrived in, each patch “contains 18 mg rivastigmine to provide 9.5 mg rivastigmine every 24 hours.” In other words, each patch contained more than the prescribed 9.5 mg dose in total. According to the medication-specific fact sheet from the manufacturer, those who assist patients with said patch are required to “replace the…patch with a new patch every 24 hours” and to “instruct patients to only wear 1 patch at a time (remove the previous day’s patch before applying a new patch).” The manufacturer further noted, “Medication errors with the…patch have resulted in serious adverse reactions…,” and “the majority of medication errors have involved not removing the old patch when putting on a new one and the use of multiple patches at one time.”
LPA observed and manager interview confirmed: Licensee did not possess an LIC602 Physician’s Report (or equivalent Medical Assessment) for R1 which had been updated within the last twelve (12) months, as was required for any resident diagnosed with Dementia.
[CONTINUED ON LIC 809-C, 2 of 2] |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/26/2024
Section Cited
CCR
87465(a)(4)
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7 | 87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by: | 1
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7 | Manager interview and personnel records, showed: On 01/24/2024, facility management met with S1 to perform written corrective coaching and retraining. Meanwhile, S2’s employment at the facility ended on 02/20/2024. Licensee also retrained its larger med pass team on what can be learned from the incident. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. |
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14 | Based on records and interviews, Licensee’s staff did not assist 1 of 163 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care. | 8
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Type B
03/26/2024
Section Cited
CCR87705(c)(5)
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7 | 87705 Care of Persons with Dementia: “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.” | 1
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7 | Licensee agreed to coordinate with R1’s physician and/or responsible person to obtain an updated LIC602 Physician’s Report for R1, and to E-mail it to LPA, by the POC due date. Licensee agreed to perform an internal audit of LIC602’s for all other current residents who are diagnosed with dementia. |
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14 | This requirement was not met, as evidenced by: Based on records and interviews, licensee did not ensure that 1 of 163 residents (R1), who was diagnosed with dementia, had a medical assessment performed within the last year, which posed a potential health, safety, and personal rights risk to persons in care. | 8
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