Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management inspection and met with Jordan Mason (Program Assistant) Shemar Lewis (Associate Director) and Kiarra Cooper (Lead Staff). The visit is due to incident reports regarding medication errors submitted to Community Care Licensing (CCL) on 10/21/24 and 11/5/24 respectively.

Per incident report dated 10/21/24, on 10/8/24 at approximately 1:30am while grave shift was conducting medication count, it was found that client (C1) was distributed 4mg of Lorazepam instead of the prescribed 2mg. Staff notified Program Director, who met with staff that passed the medications to find out what happened. Staff (S1) was passing medications and staff (S2) was verifying. They both reported that C1 was very escalated and kept distracting them when they were trying to give them their medication. Recently, this medication was reduced for C1, who used to have up to 6mg at night. S1 reviewed the process of giving these medications. When Program Director reviewed the instructions found out that it could be an easy mistake as it states to “give 2mg at night” instead of “give one two mg pill at night”. The facility added a highlighted note on the card to ensure it is clear to staff for future reference. The Program Director is working with the pharmacy to transition to different medication cards that have all the medications in one bubble pack to help prevent these mistakes in the future. According to the facility, C1 was on a higher dose prior to this incident, and there was no observed or reported side effects. During today's visit, LPA was informed by facility lead staff the mistake happened because of how the prescription was written because C1 has a prescribed Lorazepam 2mg doctor's order on file and another Lorazepam 2mg order as a PRN. Based on records review provided to LPA by the facility, C1's physician report dated 7/4/24 states prescribed medication as follow: Lorazepam 1mg in the morning (QAM), Lorazepam 2mg at night (QHS) and over-the-counter (PRN) Lorazepam 1mg every 6 hours as needed for anxiety.