Health inspection·March 28, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review, the facilty failed to administer the prescribed Morphine Sulfate (a strong pain medication) to one of five sampled residents (Resident 1) as ordered when: Residents Affected - Few Morphine Sulfate was prescribed on 2/13/24, and was given almost 24 hours later on 2/14/24. This failure had the potential to cause Resident 1 to feel discomfort while dying on comfort care. Findings: A review of Resident 1's brief interview for mental status (BIMS- evaluates cognitive impairment and can help dementia diagnosis) score of 7 indicating severe cognitive impairment. She was admitted with diagnoses of: low back pain (primary diagnosis), signs of declining cognitive function and awareness , mixed hyperlipidemia (a condition where multiple types of lipids (fats) in the blood are elevated above normal levels), and dysphagia (difficulty swallowing) among others. During a review of Resident 1's progress notes, dated from 01/01/24 to 02/28/24, it indicated, on 2/13/24 at 3:34 PM the Director of Nursing (DON) recieved the doctor's order for : Morphine Concentrate oral Solution 20mg (milligrams)/ml (milliliter), give 5mg/ml, give 5mg SL (sublingual - under the tongue) every 6 hours ATC (around the clock - scheduled for specific times of the day), and Morphine Concentrate oral Solution 20mg/ml, give 5mg/ml, give 5mg SL every 1 hour for agitation, restlessness and pain. During a review of the clinical record for Resident 1's medication administration record (MAR), dated 2/13/24 to 2/28/24, it indicated that Morphine SO4 (MSO4-chemical formula for sulfate) solution was not given on 2/13/24 and the morning of 2/14/24 .Nurses' notes are: - 02/13/2024 6:00 PM, MSO4 - Not Administered: Drug/Item Unavailable. - 02/14/2024 12:00 AM, MSO4 - Not Administered: Drug/Item Unavailable. - 02/14/2024 6:00 AM, MSO4 - Not Administered: Drug/Item Unavailable. Comment: awaiting delivery. During an interview with the Pharmacist Consultant (PC) on on 4/8/25 at 11:00 AM, PC stated, the prescription comes electronically or by fax. For the liquid Morphine, the pharmacist has to prepare it by hand. The technician cannot prepare it. If the facility needs it immediately, they have the E-kit (emergency kit - a supply of medications on-hand). At 11:37 AM PC stated, the order was received on 2/13/24 around 3:32 PM. At the time there needed to be a valid order from the doctor. The facility called on 2/14/24 at 8:32 AM. We were able to contact the doctor at 8:45 AM, and right after the Page 1 of 2 055188 055188 03/28/2025 Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403

F 0684 verbal prescription, the pharmacy authorized the facility to access the E-Kit at 8:45 AM. Level of Harm - Minimal harm or potential for actual harm During a review of the facility policy and procedure (P&P) titled Medication Administration General Guidelines, dated 2007, it indicated, 1. Medications are administrered in accordance with written orders of the prescriber[ .] Residents Affected - Few During a review of facility's P&P titled: Medication order; Controlled Substance Medication Orders 2.2, dated 2007, indicated, 14. Medications are administered within 60 minutes of scheduled time . - 055188 Page 2 of 2