Facility Evaluation Report

Licensing Program Analyst Michelle Reed arrived at the facility to conduct a case management visit. Upon arrival, LPA met with Administrator Yvette Doran. There was 1 client present during the visit. The visit was conducted to discuss an unusual incident report sent to Licensing on 10/25/22.

On 10/20/22 in the morning, Client #1(C1) was found vomiting by Staff #1(S1). C1 informed S1 that she had taken medication the night before(10/19/22) that she does not normally take.

S1 discussed the incident with the evening staff and S2 informed that she had placed the evening medications of C2 into a silver cup and C1 took the medication as she thought they were her medication.. S2 asked C2 if he took the medications. C2 said, "no."

The medications taken were Gabapentin, Lorazepam and Fanapt.

S2 was aware of the error but failed to notify Administrator Yvette Doran and seek medical treatment for C1. S2 monitored C1 throughout the night.

S2 called Administrator Yvette Doran at approximately 7:30 am on 10/20/22 and informed what took place after her peers informed her that she needed to report the incident.

Yvette Doran immediately took C1 to St. Joseph Emergency and notified her family. The Doctor's said C1 will be fine. C1's Metobolic Doctor was also called and he concurred.

An exit interview was conducted and a copy of this report and appeal rights were given to Yvette Doran.