Facility Evaluation Report

At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to a medication error reported by the facility. LPA met with House Manager Alana Roberg. A summary of the incident revealed an individual was prescribed a liquid medication and the pharmacy was having difficulty filling the prescription. Approximately 4 days later, the medication was delivered to the facility and logged in as received. The staff logging the medication failed to notify the house manager and the medication was not entered into the Medication Administration Record, (MAR). The medication was present at the facility for approximately 6 days before it was brought to the attention of the House Manager. The individual did not receive the medication during this time. House manager conducted retraining for all staff on medication procedures to ensure this incident is not repeated.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Alana Roberg and Appeal rights were given.