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SONOMA DEVELOPMENTAL CENTER 15000 ARNOLD DRIVE / P O BOX 1493 ELDRIDGE, CA 95431 June 11, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on staff interview, review of facility documents, and review of facility procedures, the facility failed to ensure patients/clients the right to receive care in a safe setting when a medication was found on a love seat in the clinic waiting room. This failure had the potential for putting patients/clients at risk of ingesting a medication that was not prescribed for them, experiencing potential side effects, and had the potential that a patient/client may have missed a dose of medication.

Findings:

On 10/29/14, review of the GER (General Event Report), dated 9/23/14, indicated a tablet of Simethicone (medication that relieves excess stomach gas) 80 mg (milligrams/unit of measure) was found unopened in the individual wrapper on a loveseat in the clinic waiting room. There were three clients in the waiting room at the time.

On 11/4/14, review of the policy for "Medication and Treatment Administration Procedures," M 601, reviewed 9/2014, contained the following entry: "Medications shall be administered at the time of preparation and shall be administered by the same licensed person who prepared the dose. Doses shall be prepared at the time of administration."


On 11/17/14 at 1:39 p.m., during an interview with Staff A, the staff member that found the tablet, Staff A stated that the packaging had a clear bubble top with a white back with the name and dose on the back. Staff A stated she was not sure if the packaging was from the facility pharmacy. Upon further investigation with Standards Compliance staff, staff provided a facility email, dated 9/23/14, that confirmed the medication was a [the name of facility] medication.