Facility Evaluation Report
Licensing Program Analyst (LPA) Jenny Olson conducted a Case Management - Incident visit to issue deficiencies on medication errors the facility has experienced. LPA met with Jaime Staine and explained the purpose of the visit.
On 08/03/2023, CCL received an incident report stating on 07/31/2023 Staff had failed to dispense Resident 1 (R1) Olanzapine 10mg tablet 3 times a day. Staff were unaware the medication changed from a PRN to routine medication. Staff spoke with R1’s doctor who changed the medication on 4/29/23. Staff found three months of Olanzapine 10mg un-dispensed in sealed medication bubble packs.
On 8/10/23, Staff stated that yesterday they were informed Resident 2 (R2) had their PRN Loratadine 10mg changed to routine on 6/13/23 but hasn't been receiving it routinely, only as a PRN. Staff stated they will submit an incident report later today.
LPA advised facility to get the MAR from the pharmacy and not make it themselves to prevent this from happening again.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).
An exit interview was conducted, a copy of the report, and appeal rights were issued.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction