Health inspection·April 25, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow professional standards of practice when a Licensed Nurse did not ensure pain medication for 1 of 3 residents (Resident 1), was administered completely before leaving the resident's room. This failure had the potential to result in the patient not taking the medication correctly, unrelieved pain, danger of other residents taking the medication, patient dissatisfaction, and loss of patient trust and confidence in the nursing staff of the facility. Findings: A review of Resident 1's admission record, indicated she was admitted to the facility on [DATE] for dizziness and giddiness, localized swelling, mass, and lump on both her lower extremities, generalized muscle weakness, pressure ulcer (wound caused by pressure on an area of the skin) of the sacral region (base of the spine) and adult failure to thrive among other conditions. A review of Resident 1's Minimal Data Set (MDS -providing information of each resident's functional capabilities and helps nursing home staff identify health problems) dated 4/5/23, indicated Resident 1 was receiving pain medication as needed (as the situation demands). During an interview on 4/12/23, at 3:32 p.m., Resident 1 stated, on the Monday following Easter Sunday (4/10/23), she waited for Licensed Nurse P (LN P) to see her. When the LN P came, LN P left Resident 1's pain medication in a cup and left without seeing Resident 1 take the medication. Resident 1 stated LN P was supposed to make sure she took the medication. During interview on 4/20/23, at 1:49 p.m., LN P stated she was informed Resident 1 was waiting for LN P for an hour. LN P stated she immediately prepared Resident 1's pain medication and went to the resident's room to administer the medication. At the resident's room, LN P stated she gave the medication to the resident but could not recall if the pain medication was in a small dispensing cup or she handed the medication into the resident's hand. LN P stated when she saw the resident move forward, she assumed Resident 1 was thanking her and left the room. LN P acknowledged she did not see the resident take her medication before she turned and headed back to the nurse's station. During a subsequent interview on 4/24/23 at 3:40 p.m., LN P stated she had not asked the pain level of Resident 1 before and after she gave the pain medication. LN P stated Resident 1's pain level was monitored every shift and before and after administration of pain medication. During a review of Resident 1's Controlled drug record documenting the date and time Percocet, a brand name for a narcotic (medication that dulls the senses and relieves pain) containing 5 milligrams (mg - unit of measure) of oxycodone, and 325 mg acetaminophen (pain reliever), indicated 1 tablet Page 1 of 2 055222 055222 04/25/2023 Springs Road Healthcare 1527 Springs Road Vallejo, CA 94591

F 0726 of Percocet was given to Resident 1 on 4/10/23 at 3:00 p.m. Level of Harm - Minimal harm or potential for actual harm A review of the policy titled, Administering medications revised 4/2019, indicated medications are administered in a safe manner, and as prescribed. Resident may self-administer their own medications only if the attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Residents Affected - Few During an interview on 4/15/23, at 11:26 a.m., the Director of Nursing (DON) stated the facility performs assessments of residents who prefer to self-administer their own medication. A physician's order is obtained when a resident is assessed safe to self-administer his/her own medication. The DON stated a Licensed Nurse reminds the resident of the schedule and supervises the self-administration of the medication. The DON stated that the licensed nurse must be physically present and witness the resident take and swallow the medication before documenting the medication administration. The DON confirmed Resident 1 did not have an order to self-administer her own medication. 055222 Page 2 of 2