Health inspection·September 5, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure documentation in the clinical record was accurate for one of two residents (Resident 1) when: 1. Licensed nurses (LN) documented Lithium (a mood stabilizing medication) as having been administered to the Resident 1 when the medication was unavailable. 2. Resident 1 ' s documented behavior monitoring did not reflect accurate observations of the resident ' s behavior. As a result, Resident 1 ' s clinical record did not accurately reflect the care and treatment that was provided. Findings: A review of Resident 1 ' s admission Record indicated, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include schizophrenia (mental illness characterized by paranoia, hallucinations, and/or delusions) and acquired absence of left upper limb above the elbow. 1. On 9/5/24, a record review was conducted. Resident 1 ' s readmitting orders from [hospital name] dated 8/19/24, indicated the resident was to take Lithium 300 milligrams (mg) twice a day. A review of Resident 1 ' s medication administration record (MAR) for August 2024 indicated, Lithium 300 mg was given in the morning and evening on 8/20/24, and in the morning on 8/21, 8/23, 8/24, 8/25, 8/26, and 8/27/24. A review of Resident 1 ' s progress notes dated 8/26/24 indicated, Call pharmacy and spoke to [name omitted] regarding medication Lithium Carbonate oral tablet 300 mg. She stated that she doesn ' t see this medication on her side . The progress note further indicated the pharmacy had not dispensed Resident 1 ' s Lithium 300mg as they believed the resident was allergic to Lithium. A review of Resident 1 ' s progress notes dated 8/27/24 at 11:57 A.M., indicated the pharmacy was notified that the nurse practitioner had discontinued the resident ' s allergy to Lithium. The pharmacy was asked again to dispense and send Resident 1 ' s Lithium to the facility. On 9/5/24 at 1:36 P.M., a joint interview and record review was conducted with LN 3. LN 3 reviewed Page 1 of 3 055182 055182 09/05/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 ' s August 2024 MAR and stated he was assigned as the resident ' s medication nurse on 8/25/24. LN 3 stated Resident 1 ' s Lithium was not dispensed from the pharmacy when the resident was readmitted on [DATE] because they thought the resident was allergic to it. LN 3 stated he documented that he gave Resident 1 the Lithium 300 mg at 9 A.M. on 8/25/24. LN 3 stated that documentation was in error. LN 3 stated it was not possible to give Lithium to Resident 1 as the medication had not been dispensed by the pharmacy until 8/27/24. LN 3 removed Resident 1 ' s Lithium 300 mg medication card (individual pills on a card for daily administration) from the medication cart. Resident 1 ' s Lithium medication card was dated 8/27/24 and one dose was empty on the card (#14). LN 3 stated the date of 8/27/24 on the card meant the pharmacy dispensed the medication on that day and that the medication would have been brought to the facility sometime in the evening on 8/27/24. LN 3 further reviewed Resident 1 ' s August 2024 MAR for Lithium 300 mg and stated when LNs documented they gave Lithium in the morning and evening on 8/20/24, and in the morning on 8/21, 8/23, 8/24, 8/25, 8/26, and 8/27/24, that was all in error. LN 3 stated Resident 1 ' s Lithium was not available to give until evening on 8/27/24 or the next day (8/28/24). LN 3 stated the documentation in Resident 1 ' s MAR should have been accurate. On 9/5/24 at 2:23 P.M., a joint interview and record review was conducted with LN 4. LN 4 reviewed Resident 1 ' s August 2024 MAR and acknowledged her documentation on 8/26/24 as having administered Lithium to the resident at 9 A.M. LN 4 stated she could not recall anything about Resident 1 ' s Lithium. LN 4 stated documentation in the residents ' clinical records should accurately reflect care and/or treatment that was rendered. 2. A review of Resident 1 ' s August 2024 medication administration record (MAR) was conducted. Resident 1 was receiving Risperidone (antipsychotic medication to treat psychosis) and had behavior monitoring associated with the medication. The MAR indicated, .Monitor episodes of psychotic behavior AEB [as evidenced by]: striking out toward others (Risperidone) Review of Resident 1 ' s MAR indicated the resident manifested the behavior striking out toward others twice on 8/23/24, five times on 8/24/24, six times on 8/25/24, six times on 8/27/24, and three times on 8/28/24. On 9/5/24 at 1:36 P.M., a joint interview and record review was conducted with LN 3. LN 3 stated he was familiar with Resident 1 and had been the resident ' s assigned nurse on 8/25/24. LN 3 reviewed Resident 1 ' s clinical record and his documentation on the resident ' s MAR on 8/25/24 for Risperidone behavior monitoring. LN 3 stated striking out toward others meant the resident had hit someone or attempted to hit someone. LN 3 stated he had documented this behavior as having occurred 3 times on 8/25/24 and that this documentation had been in error. LN 3 stated he had never seen Resident 1 strike or hit another person, nor attempt to do so. LN 3 stated by inaccurately documenting the resident striking out three times, it appeared there was an issue with this behavior. LN 3 stated if Resident 1 struck or hit someone, this would have needed to be reported to the physician. LN 3 stated the documented observations of Resident 1 ' s behavior should have been accurate. On 9/5/24 at 1:50 P.M., a joint interview and record review was conducted with LN 5. LN 5 reviewed Resident 1 ' s clinical record and stated striking out toward others meant attempting to or actually hitting another person. LN 5 stated she never saw Resident 1 strike another person. LN 5 stated Resident 1 would swing his amputated arm when walking in a manner that was taunting. LN 5 reviewed her documentation on Resident 1 ' s MAR on 8/23, 8/24, and 8/27/24 and acknowledged she had documented episodes where Resident 1 was observed striking out toward others (twice on 8/23, twice on 8/24, and 055182 Page 2 of 3 055182 09/05/2024 Lemon Grove Care and Rehabilitation Center 8351 Broadway Lemon Grove, CA 91945

F 0842 Level of Harm - Minimal harm or potential for actual harm three times on 8/27/24). LN 5 stated she documented those episodes when Resident 1 moved his amputated arm in a taunting manner. LN 5 stated she did not have a place to document those observations and recorded them as striking out toward others. LN 5 stated she should have clarified the behavior monitoring order. LN 5 stated her documentation should have been accurate and that inaccurately documenting Resident 1 ' s behavior, Gives the wrong idea of the resident ' s behavior. Residents Affected - Few On 9/5/24 at 2:23 P.M., a joint interview and record review was conducted with LN 4. LN 4 stated she saw Resident 1 swing his amputated arm at the corner of his room, but not at anyone. LN 4 reviewed Resident 1 ' s August 2024 MAR and stated she documented Resident 1 as striking out at others three times on 8/26 and three times on 8/28/24. LN 4 stated she did not observe the resident striking at anyone only swinging his amputated arm. LN 4 stated she should not have documented observing Resident 1 swing his amputated arm as striking out at others and that her documentation had not been accurate. On 9/5/24 at 3:11 P.M., an interview was conducted with the director of nursing (DON). The DON stated the LN documentation in Resident 1 ' s MAR should have been accurate. The DON acknowledged Resident 1 ' s Lithium was not dispensed from the pharmacy until 8/27/24. The DON stated LNs should not have been documenting that they gave a medication that they did not give. A review of the facility ' s policy titled Charting and Documentation revised 1/2023, did not provide guidance related to the accuracy of documentation. 055182 Page 3 of 3