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25 | Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management visit to the facility regarding a self reported incident. In addition, LPA conducted a visit regarding 911 calls made by the facility which were not reported to Community Care Licensing (CCL). LPA met with Health Services Director Daniel Orozco (Orozco), LVN and LPA explained the purpose of the visit. The current interim facility Administrator/Executive Director Krystal Jenkins was not at the facility during LPA's visit. LPA arrived at the facility at 1:15 p.m. and interviewed staff at 1:20 p.m. LPA reviewed resident and employee records at 2:20 p.m.
The facility reported to CCL that on 12/17/2021 at approximately 5:20 p.m., Resident #1 (R1) was mistakenly given medications meant for Resident #2 (R2) by Staff #1 (S1). S1 immediately realized the error and reported it to other staff and management. S1 was instructed to called 911 and R1 was taken to the hospital. R1 received treatment and was discharged back to the facility at approximately 9:26 p.m the same evening. Orozco stated S1's error was due to not paying close attention during the med pass; R1 and R2 have similar first names and S1 mistakenly handed the wrong container to R1. S1 has been removed from the medication technician position pending re-training.
Orozco stated he is the individual who reports unusual incidents to CCL. He indicated he is informed by facility staff of all 911 calls and he reports those incidents to CCL. He stated the facility fax machine was having issues and it is possible the faxed reports did not go through. LPA informed Orozco he can email the incident reports to avoid these issues in the future and provided Orozco with the email address. LPA requested information regarding the 911 incidents that were not reported. Orozco said he would gather the information and forward it to LPA. Orozco was headed into two care meetings scheduled with families.
LPA will return at a later date to continue reviewing records and possibly conduct further interviews. No deficiencies cited at this time. Exit interview conducted. A copy of the report was reviewed and issued. |