Complaint·February 21, 2023

Regarding the allegation: Staff are not following physician's orders It was alleged that staff failed to follow physician’s orders for R1 and R2. Regarding R1, it was alleged that R1's fentanyl patch had not been changed every 72 hours as prescribed. The LPA reviewed hospice records for R1, and the LPA observed that the order for R1’s fentanyl patch stated that it was to be applied “transdermally every 72 hours for pain and remove per schedule”. When the LPA initially interviewed the Health Services Director on 07/27/2022, the staff stated that they had counseled staff on remembering to remove and assist R1 with applying a new fentanyl patch every 72 hours as instructed. Hospice notes revealed that a hospice representative had discussed this concern of failing to remove the fentanyl patch within 72 hours with staff on 06/27/2022. During the initial visit on 07/27/2022, the LPA received a copy of R1’s electronic Medication Administration Record (eMAR) for July 2022. Staff indicated that for the fentanyl patch, staff technicians were required to document the dates and times that R1 was assisted with the self-administration of the fentanyl patch in the eMAR, and staff were required to hand-write when the patch was administered to R1 on the ‘Controlled Drug Record’ form. Staff indicated that the dates on the eMAR and Controlled Drug Record should match. Per review of the eMAR on 07/27/222, staff indicated that R1 was assisted with the self-administration of the fentanyl patch on the following dates: 7/1/2022, 7/4/2022, 7/7/2022, 7/10/2022, 7/13/2022, 7/16/2022, 7/19/2022, 7/22/2022, and 7/25/2022. Per review of the eMAR alone, it would appear that R1 was assisted with the self-administration of the fentanyl patch every 72 hours as prescribed. On 07/27/2022, the LPA obtained the ‘Controlled Drug Record’ for July 2022. As previously stated, staff indicated that the dates on the eMAR and what was written on the Controlled Drug Record form should match. The ‘Controlled Drug Record’ form kept count of the fentanyl patches, as the patches were provided in quantities of five (5) from the pharmacy. Per review of the Controlled Drug Record form, staff documented that R1 was assisted with the self-administration of the fentanyl patch on the following dates: 7/3/2022, 7/8/2022, 7/10/2022, 7/14/2022, 7/16/2022, 7/19/2022, 7/22/2022, 7/25/2022. Staff were unable to explain why the days did not align, specifically the days between 7/1/2022 – 7/14/2022. Staff believed that as the Controlled Drug Record form kept count of the fentanyl patches administered to R1, it was likely that the hand-written form was a more accurate representation of the dates and times of when the medication was administered. Staff also noted that there may have been a challenge with obtaining refills within the allotted time frame to ensure that R1 received the medication timely. As such, per review of the Controlled Drug Record form, R1 did not receive the fentanyl patch within 72 hours as prescribed between the dates of 7/3/2022 and 7/8/2022, and 7/10/2022 and 7/14/2022. Regarding R2, it was alleged that R2 was not receiving their routine Morphine and Lorazepam, which was to be administered every four (4) hours. The LPA reviewed physician orders dated 7/18/2022, in which R2 was prescribed to start Lorazepam 1mg every four (4) hours routinely, and it was to be administered with Morphine 15mg tablet. Both medications were to be crushed and added to 0.25-1ml of water. The LPA reviewed the Controlled Drug Record starting on 7/18/2022 (evening), and noted that R2 was assisted with Lorazepam and Morphine on the following times: 7/18/2022 at 8:00 p.m.; 7/19/2022 at 8:30 a.m., 4:00 p.m. and 8:00 p.m.; 7/20/2022 at 8:30 a.m.; 7/21/2022 at 9:00 a.m., 4:00 p.m. and 8:00 p.m.; nothing documented for 7/22/2022; on 7/23/2022 at 12:00 a.m.; on 7/24/2022 at 8:00 a.m. and 12:00 p.m.; on 7/25/2022 at 8:30 a.m. and 1:50 p.m.; on 7/26/2022 at 8:28 a.m., 12:30 p.m., 4:00 p.m., and 8:00 p.m.; and, on 7/27/2022 at 9:00 a.m. A review of R2’s eMAR indicated that for all but one the prescribed times of 12:00 a.m. and 4:00 a.m. between the dates of 7/19/2022 – 7/27/2022, staff indicated ‘6’, that R1 was asleep during those times. Yet the eMAR also indicated that R2 was assisted with the medication at 8:00 a.m., 12;00 p.m., 4:00 p.m., and 8:00 p.m. These dates do not match up with what was documented on the Controlled Drug Record; in particular, for the 7/22/2022 date, staff did not record that any medications were provided to R2 on the Controlled Drug Record for 7/22/2022, yet they are documented as administered on the eMAR. Interviews conducted on 7/27/2022 with staff indicated that if R2 was asleep, they would not assist R2 with the self-administration of the required medication. However, an interview with the hospice nurse confirmed that as this was a routine medication, R2 was to be awoken and provided with the medication. An interview with a family member of R2 and R2’s nurse supported claims that staff were not coming in during the evenings or throughout the night to ensure that R2 received the medication. It was communicated that without the medication, R2 would become agitated and would continue to experience pain. Yet, staff interviews on 2/17/2023 and 2/21/2023 indicated that residents should be woken up to receive medication if it is indeed a routine medication. Documents support claims that R2’s Morphine and Lorazepam were routine medications. Based on the information obtained in interviews and observations, there is sufficient evidence to support claims that staff were not following physician’s orders. This allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 9099-D). Exit Interview Conducted. Appeal Rights Discussed. A Copy of the Report Issued. Regarding the allegation: Staff do not answer residents call lights timely It was alleged that staff fail to respond to resident call lights timely. Staff interviews revealed that R1 did press their pendant often but claimed that not all of the requests were emergencies. Staff said they would attempt to get to R1 and others in a timely manner. At the time of the request, the facility did not have the records for the call buttons for July 2022. Hence, the LPA interviewed staff, residents, and reviewed records for the call buttons for February 2023 for the dates between 2/1/2023 – 2/16/2023. The LPA identified that on average, the facility staff responded to an average of sixty-two (62) call lights a day. This number does not necessarily mean that sixty-two (62) residents on average need assistance in a day, as records indicated that there were residents that would press their pendant or utilize their pull cord multiple times throughout the day. Whereas some residents felt that the staff failed to respond to call lights timely, the LPA observed that per the daily average taken from the requested call light records, there were an average of three (3) call buttons where it took between 20-30 minutes to respond. Per the average, the staff respond to approximately 95% of call lights in under 15 minutes. Staff claimed that it may take time to respond to a call light if they are assisting another resident with changing, toileting, or a shower. Based on the information obtained in interviews and records review, there is insufficient evidence to support the claim that staff did not answer resident call lights timely on a regular basis. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.