Facility Evaluation Report

On 6/20/23 at 9:30am Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management deficiencies inspection to address a self reported medication error. LPA met with Administrator Neal Torres to discuss the reported incident.

Administrator confirmed that there was a medication error regarding the administration of a resident's insulin on 6/9/23. LPA met with the resident who could not recall the medication error and reported feeling no negative effects from the error. Facility contacted the resident's physician and poison control to ensure the safety of the resident. Facility has already conducted in services training with the staff member and has resumed several days of shadowing during medication pass. Facility continues to make adjustments and clarity for insulin administration and continues to evaluate electronic medication administration records (EMARs) for incorporation into the facility's medication administration process.

LPA, Administrator and Resident Care Coordinator discussed additional steps the facility can take to eliminate additional medication administration errors. LPA and administrator reviewed the Health and Safety Code for employees assisting residents with self administered medications and reviewed the Department medications guide and a copy was provided to the administrator for distribution.

Per California Code of Regulations, Title 22, the following deficiency is cited. Due to a previous citation in the past 12 months, a civil penalty is issued.

An exit interview was conducted, a copy of this report and appeal rights were left at the facility.