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25 | Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Administrator, Lucero Rodriguez and Director of Operations, David Sandhu.
The purpose of the visit is to follow-up on an incident report the Department received regarding a medication error for resident (R1). On 07/29/2024, during a nightly medication audit, it was discovered that R1 did not receive his/her 8AM and 8PM doses of medication on 07/27/2024 and 07/28/2024. R1's doctor was notified and directed the medication to be started with the AM dose on 07/29/2024.
During visit, it was stated that after the incident they assigned re-training for all the staff regarding medications. The lead that was involved in the incident was provided in-person training with the leadership. It was stated that the facility is being proactive by providing all leadership staff additional training regarding medications. The leadership team is currently working on developing strategies to implement to avoid future medication errors.
Documents were obtained to include the facility's medication program design, staff training records and email correspondence regarding communication from the doctor to staff regarding the change in R1's medication.
No deficiency was cited per California Code of Regulations, Title 22. Advisory note provided. A plan of correction was requested for the advisory note.
This report was reviewed with Administrator, Lucero Rodriguez and Director of Operations, David Sandhu and a copy of the report was provided. |