Facility Evaluation Report

Licensing Program Analyst (LPA) Vicky Williamson conducted an unannounced case management visit to follow up on a self- reported incident, received by Community Care Licensing on 10/2/22. LPA was granted entry into the facility by Program Director Carolina Nunez-Garcia , to whom LPA discussed the purpose of the visit.

The facility self- reported a medication error involving three facility staff administering the incorrect prescription of medication to Client 1(C1). On 8/25/22, an incorrect prescription for Rifabutin 150 mg was submitted to the pharmacy by Staff 1 (S1), instead of Rifampin 300 mg. On 8/26/22, the medication Rifabutin 150 mg was received at the facility by Staff 2 (S2).

The medication Rifabutin 150 mg was administered for the first time on 8/28/22, by Staff 2 (S2), and was continuously administered daily by S1, S2 and S3 (LIC 811 Confidential Names provided to Program Director) through 9/24/2022, instead of Rifampin 300 mg x 2. Per Sharon Simmons, Director of Nursing (DON), C1 did not experience any adverse effects from the Rifabutin.

On 9/25/22, Sharon Simmons, Director of Nursing (DON) was notified by Staff 4 ( LIC 811 Confidential Names provided to Program Director) that the medication Rifabutin 150 mg had been dispensed to C1 instead Rifampin 300 mg. S4 verified that the label on the bottle of the Rifabutin 150 mg did not match the Medication Administration Record (MARS). DON spoke with C1 and they confirmed that they had been administered the medication daily. DON requested that S4 hold the medication because there was no coinciding medication order for Rifabutin. On 9/26/22, DON contacted Imperial County of Public Health, and spoke to a nurse (LIC 811 Confidential Names provided to Program Director) to verify medication regimen for Rifampin. It was confirmed that C1 should be taking Rifampin 300 mg x 2, and to restart the medication immediately. C1's Nurse Practitioner was contacted by DON.