Facility Evaluation Report

Licensing Program Analyst (LPA) Tihesha Smith conducted a Case Management- Incident visit. LPA met with staff and explained the reason for the visit.

On 10/25/22, the department received a self-reported incident report stating that Client #1 (C1) was given bedtime (PM) medications instead of morning (AM) medications. It was revealed that on 10/23/2022 Staff #1 (S1) did not follow medication administration protocol by not allowing Staff #2 (S2) to final check the collection of medication being administered before medication was given to the client. LPA clarified over the phone that C1 did not receive their full collection of prescribed morning (AM) medication and received the bedtime collection of medication instead.

Per administrator there have been no adverse effects on C1 as a result of the incident. The administrated revealed the doctor for C1 was contacted on 10/23/22 and informed of the incident. The clients’ doctor advised to monitor client and take to emergency room if vitals are not stable. Training was provided to all staff on medications policy, medication handling and three check system before administering. C1 has not seen a doctor as a result of this incident.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency was cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.