Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced visit at the facility in conjunction with an investigation of complaint control # 18-AS-20231129162111 .

During today's investigation, LPA observed deficiencies unrelated to the complaint allegations. During record review, LPA observed that at the time of the alleged medication error (05/19/2023 and 05/20/2023), that Resident #1 (R1)’s metoprolol tartrate 50mg was prescribed “take 0.5 tab (25mg) by mouth twice daily for hypertension only take if heart rate >75.” Staff interviewed indicated that staff do not take resident heart rate readings, as medication technicians are not skilled medical professionals and that residents with parameters in their prescription orders must be able to take their own readings prior to medication administration. Staff interviewed stated that R1 would measure their own heart rate. When the med tech would go to R1’s room to administer medications, the med tech should have asked R1 what their heart rate was and confirm with R1 whether the medication should be administered or held based on R1’s heart rate reading. However, the medication technicians working on 05/19/2023 and 05/20/2023 were not the regular medication technicians at the time of the alleged error. Review of R1’s MAR indicates the medication was administered by one medication technician twice (in the morning on 05/19/2023 and 05/20/2023) and by another staff at night on 05/19/2023. These were the only 3 (three) times the medication was administered at all from May 2023 to November 2023. Interview revealed that staff did not ask R1 what their heart rate was or confirm whether the medication was needed or should be held, as ordered. R1 and their family member recall R1 requiring outside medical attention due to low heart rate following the 3 (three) times this medication was administered, however the facility did not have documentation reflecting this.

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

Exit interview conducted, today's reports and appeal rights were reviewed and issued.