19. Unannounced Visit: Medication Errors

Hours:    None

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Facility Type: 740 (RCFE)

Investigation Findings
A Case Management visit was conducted by Licensing Program Analyst (LPA) who met with Life G Director.

The facility has experienced numerous medications errors which has been an ongoing concern. LPA printed and reviewed incident log with the facility staff.

The month of Sept 2017 there were 18 noted medication issues reported; for the month of Oct 2017 there were 11 noted medication issues reported. The noted issues involved residents missing a medication or staff error involving wrong dosage.

Some instances of missed medications may have been due to circumstances with residents being in the community, pharmacy delays, or families not bringing in a medication, but multiple were staff-related.

The last two reports from 10/27/17 – 10/28/17 involved residents #1-2 who had three medications issues during that period due to staff error.

Resident #1 was given the wrong dosage of nasal spray on 10/27/17 and 10/28/17 while resident #2 missed a dosage of Norco 5-325 mg on 10/28/17.

Facility attributes medication errors to new staff.

The following deficiencies were observed at today’s visit (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided. Plans of corrections were discussed.

“A” citations may pose a Health and Safety risk.

Deficiency Type /
Section Number
Type A
Section Cited
Incidental Medical and Dental Care Services 87465(a)(5). The licensee shall assist residents with self-administered medications when needed.
This requirement is not met as evidenced by: based on the fact that the licensee failed to ensure that staff when assisting R#1-2 with their medications resulted in staff #1 getting the wrong dosage of nasal spray on 10/27-10/28 and R#2 missing a dose of Norco 5-325 mg on 10/28/17.
A repeat violation within 12 months occurred so a $250 civil penalty applied.
Licensee agrees to ensure that med techs are assisting residents with the proper dosages of medications. Licensee agrees to immediately pull staff #1 from medication passing until the staff has been re-trained; completed more shadowing and has shown to be proficient in medication passes without errors. Licensee will send to CCL a written plan of S#1's training plan and scheduling to show training; shadowing and successful med passes before working alone. Licensee will also provide a copy of facilities policy for MARS audit to ensure errors are being caught timely. Above items will be sent to CCL by 11/13/17.


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