Inspector’s narrative
What the inspector wrote
[CONTINUED FROM LIC 9099]
Per their LIC602 Physician’s Report, R1’s primary diagnosis was “Mild Cognitive Impairment” and they needed help with “medication management.” In R1’s Pre-Admission Resident Appraisal, licensee wrote, “[R1] needs med management…” In R1’s Service Plan / Plan of Care, licensee wrote, “[R1] needs assistance with self-administration of medications,” “[R1] requires daily supervision of medication,” and “[R1] will be supported to take all medications safety as ordered.”
Hospital records showed R1 presented to an Emergency Department (ED) on 02-19-2021 complaining of shortness of breath, decreased urine output, and fluid retention in their belly and legs. Lab tests showed R1’s blood potassium on arrival was 7.0 mmol/L (versus the test’s normal reference range of 3.5 to 5.1 mmol/L). ED staff withheld R1’s Potassium Chloride medication, and by 02-25-2021 their measured blood potassium was back within normal range. Per hospital records, R1 told ED personnel: Cloisters’ staff “organizes the medication and they are administered according to the way they are prescribed…” and their medicine prescriptions “got messed up” when they moved into Cloisters. R1 told doctors they were prescribed twice the amount of Potassium Chloride, and half the amount of Bumex, that they wanted for themselves.
According to medical records, prior to R1’s 02-19-2021 hospitalization, they were prescribed: a) two 20 mEq tablets of Potassium Chloride, two times per day, and b) one 2 mg tablet of Bumex, two times per day. Upon discharge from the hospital on 02-25-2021, R1’s Potassium Chloride was stopped completely, and their Bumex order was kept the same as pre-admission. According to Cloisters’ Medication Administrator Records (MARs) for R1 during January 2021 and February 2021: leading up to R1’s 02-19-2021 hospital trip, staff gave R1 their Potassium Chloride and Bumex according to their respective prescriptions. Upon R1’s return to Cloisters, staff gave R1 their Bumex like before and halted their Potassium Chloride, consistent with the hospital’s discharge orders. Based on the evidence obtained, Licensee was not culpable for causing R1’s elevated potassium levels or hospitalization.
[CONTINUED ON LIC 9099-C, 2 of 3]
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CCLD reviewed MARs for five residents [R1, Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5)], for the period from January 2021 through mid-July 2021. During this review period: R1 had 76 missed medicine doses (meaning they were not offered to R1). They involved nine different medicines and affected all months of the review period. Also, R2, R3, and R4 each had multiple missed doses of different medicines, affecting multiple months. Per staff notations on the MARs, some missed doses were due to staff awaiting delivery of medicines from the pharmacy, but there were also many missed doses with no comments/explanations provided..
CCLD interviewed 8 medication technicians and manager Staff #2 (S2), who provided general oversight to that team. S2 and 7 med techs said facility staff were responsible for obtaining R1’s medicine refills before they ran out, and while most residents’ medicines refilled automatically from licensee’s contracted pharmacy, staff also manually reordered medicines if they saw pills were running low. 5 med techs said they were required to contact the pharmacy for refill(s) if a resident had 6 to 7 days of pills remaining; S1 and other med techs said this was required 4 to 5 days before running out. 6 med techs said one of R1’s prescribed medicines frequently had its dose titrated/adjusted by R1’s physician. Sometimes the pharmacy could not dispense the medicine due to needing authorization/clarification from the doctor, resulting in delays, and missed doses. CCLD asked staff how they resolved these physician-authorization delays but received conflicting responses: some said they contacted R1’s physician who usually responded, some said they contacted R1’s physician who rarely responded, and some said Cloisters staff did not contact R1’s physician at all. CCLD asked the med techs if there were occasions residents missed doses, not due to authorization problems, but simply due to Cloisters staff being too slow to order medication refills: 4 med techs said missed doses due to late ordering occurred on multiple occasions.
In reference to the second allegation (regarding dignity), R1 told CCLD that they handed a paper to S1 showing their preferences for heart-healthy foods, but S1 crumpled it up in front of them and threw it away. R1 said they felt disrespected on other occasions too. In their interview, S1 denied having interpersonal conflict with R1, and confirmed receiving a list of heart-healthy food preferences from R1. S1 said they always followed this list, but when CCLD asked for examples of food adjustment they made to support R1 with this list, S1 could not name any.
[CONTINUED ON LIC 9099-C, 3 of 3]
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CDSS interviewed several non-managerial staff about the allegation: Staff #3 (S3) witnessed S1 ignore R1’s food request, then take steps to prevent other staff from meeting R1’s food request. S3 witnessed S1 speak to R1 using profanity. Staff #4 (S4) witnessed R1 request heart-healthy food but S1 rudely dismissed them. S4 witnessed S1 speak disrespectfully to other residents and staff too. Staff #5 (S5) said S1 did not honor residents’ food requests and was abrasive with R1, other residents, and other staff, to include public confrontations with managers. Staff #6 (S6) witnessed S1 slam pots and pans inside the kitchen in frustration, and said coworkers complained to them that S1 refused to accommodate residents’ food preferences. Staff #7 (S7) said S1 had a reputation for being rude. Employee records show S1 was formally disciplined/counseled regarding accommodating residents’ dietary preferences/requests, working collaboratively with others, and professional speech and conduct, among other topics.
Based on interviews and records, the preponderance of evidence shows licensee did not give R1, R2, R3, and R4 their medications as prescribed, and that S1 did not treat R1 with dignity. Both allegations are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Dizon, to whom a copy of this report, the LIC 9099-D, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
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CCLD reviewed R1’s two LIC602 Physician’s Reports, dated 03-26-2020 and 01-06-2021: on both documents, for the box titled “Special Diet,” the physician checked “No.” R1’s LIC603 Preplacement Appraisal did not indicate a physician-prescribed special diet. The Preadmission Resident Assessment which licensee completed on R1 said they were on a “regular” diet. R1’s Service / Care Plan said they were “independent with meals and eating and drinking” and “Diet: Regular.” CCLD reviewed the facility’s care file on R1 but encountered no evidence of R1 being on a physician-prescribed special diet.
Based on interviews and records, there does not exist a preponderance of evidence to show that facility staff did not follow a physician’s dietary order for R1. The allegation is therefore unsubstantiated. An exit interview was conducted with Dizon, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.
