Complaint Investigation Report

Interviews and records review revealed that in February 2023, R1 was given another resident's medication by staff at around 7:00pm. Interviews and records review revealed that the medication error was discovered approximately 3 hours later. Interviews revealed that 911 was contacted at that time to assess R1 for any side effects to ingesting the medication. The paramedics contacted Poison Control and assessed R1 and determined that R1 did not need to be transported to the hospital. Facility staff conducted safety checks every 30 minutes for the next 7 hours until R1 requested to conclude the safety checks. R1 did not verbalize any side effects of ingesting the incorrect medication.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Executive Director Sam El-Rabaa, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.