1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility’s case management – incident visit. LPA met with Associate Director, Jon Flint and Administrator, Jennifer Ryder.
The purpose of the visit was to follow-up on incident reports regarding medication errors. On 11/15/2023 and 01/16/2024, the Department received incident reports for resident (R1) regarding medication errors. During visit, LPA interviewed 2 staff members and observed the medication room.
The first incident reported in November 2023, reported that R1 had missed a weekly vitamin that is to be dispensed every Wednesday. The error was noticed on Saturday. Based on interview, the medication was signed off in the system, however, the medication was not actually dispensed. The medication error was caught by another staff member who immediately informed the ADM. The ADM reached out to R1's physician who provided instructions. R1's conservator was also notified. After the incident, the facility verbally debriefed with the staff and informed the staff on the importance of using their electronic MAR scanner to assist with medication to prevent errors. R1 was reported to be doing well with no changes of condition.
The second incident reported in January 2023, reported that R1 missed a medication. Based on the report and interview, R1 missed the medication because the previous staff did not throw out the empty sleeve of medication, causing it to appear as if there was an adequate stock of R1’s medication.
SEE LIC809-C. |