Facility Evaluation Report

LPA arrived unannounced to conduct a case management regarding Incident Report received on 11/06/2023 and to address Department of Developmental Services (DDS) report findings from DDS report dated 11/06/2023.

Per facility’s Incident Report: On 11/02/2023 at approximately 2pm the resident (R1) had a missed dose of medication. Per the incident report, the technician did not get all of the resident's medication from storage, they left some pills in a bubble pack. The staff that gave the medication did not check the packs and meds afterwards. No one else checked the packs and the medication log after to make sure that the resident received the correct medication. Per Title 22 regulation 80075(b) Health Related Services, Clients shall be assisted as needed with self-administration of prescription and nonprescription medications ( deficiency cited, see 809D ).

Per LPA interview with Admin once staff identified the missed dose for R1, staff alerted both administrators. Administrator contacted resident's doctor, doctor advised not to administer missed dose but proceed with regularly scheduled next dose. Per Admin staff closely monitored R1 for any adverse affects from the missed dose of medication. As of today, the resident still has not shown any signs of an adverse affect from the missed dose.

Per LPA interview with Administrator, facility conducted a meeting with all staff about the missed dose that occurred and Admin requested a nurse to conduct an in-service training for medication administration, nurse will be here 12/27/2023 to conduct additional training. Per Admin, staff has received training as how to ensure proper administration of medication for all residents: They have designated one staff person to give meds without other responsibilities. They have designated a specific location away from central activities to administer medication. They have reorganized the medication storage to be more simplified and clear. Facility has a plan for making sure everyone has information that they need in order to administer medication properly. Facility has implemented a plan to check to see that all residents' medications have been administered properly, which includes checking medication cups and bubble packs to make sure they are empty after each medication pass and have a second person checking medications and medication logs. Staff has implemented alarms on their phones, in particular for R1 as an additional reminder to administer medications when due. LPA verified R1's care plan was updated after incident of missed medication.