Facility Evaluation Report

On 08/12/22 at 12:45 PM, LPA L. Holmes conducted an unannounced case management visit. No one was at the facility. LPA telephone Administrator (ADM) Pia Webster, she is in Berkeley and can return. LPA explained the purpose of the visit was to discuss the self reported incident received by CCL on 08/06/22 regarding a medication error. ADM arrived at 01:20 PM.

On 08/09/2022 at about 8:00 AM, Administrator, Pia Webster (ADM) received a telephone call from the Direct Support Professional (DSP)/Staff #1 (S1) stating that he/she had given Consumer/Client #1 (C1) the meds that belonged to Consumer/Client #2 (C2). S1 stated that he/she was rushing around and answered the front door. When S1 returned to administering medication to C1, he/she realized after C1 took the medication that was for C2. S1 had administered the wrong medication to C1. C1 received the following medications: (Antihypertensive) Benazepril/HCTZ 10-12.5mg x1, (Antidepressant) Citalopram 20mg (1/2 tab), and (Antidepressant) Citalopram 10mg (1/2 tab). C1’s primary medical doctor, psychiatrist and Nurse Kaman were contacted, no new orders were received and C1’s doctor is to follow-up. C1 was monitored throughout the day and there was no change in conditions. R2’s replacement medication was ordered from the Pharmacy the same day and to arrive on 08/12/22. The MAR’s for C1 and C2 are accurate, completed and up to date for 08/2022.