Health inspection·September 25, 2023

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary drugs by failing to: Residents Affected - Few 1.Obtain an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for the use of a psychotropic medication (drug that affects brain activities associated with mental processes and behavior) for depression (persistent sadness and a lack of interest or pleasure)per the facility's policy and procedure (P&P). 2. Implement a care plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments) for depression per facility's P&P. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including pericardium disease (an inflammation of the pericardium or sac that contains your heart), hypertension (high blood pressure) and hyperlipidemia (high cholesterol). During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 10/29/2021, indicated that Resident 1 was alert and oriented and able to make decisions regarding activities of daily living. During a review of Resident 1's Physician Order dated 10/23/2021, indicated order for Celexa (medication used for depression) 30 milligrams (unit of measurement) by mouth once daily for depression. During a review of Resident1's Medication Administration Record (MAR) dated 11/1/2021-11/30/2021, indicated Resident 1 received Celexa by mouth daily from 11/1/2021-11/20/2021 and 11/22/2021-11/24/2021. During a review of Resident 1's informed consent (IC) form for psychotropic medications, the IC form was not signed by Resident 1 and physician to administer a psychotropic medication. The IC form did not indicate the risk and benefits of Celexa medication was explained to Resident 1 by the physician as stated in facility's P&P. During a concurrent interview and record review on 9/22/2023 at 3:15 pm with the Director of Nursing (DON), stated prior to administration of antidepressant medication (medication used to treat depression) including Celexa, an informed consent should be obtained to ensure Resident 1 was informed of Page 1 of 2 055353 055353 09/25/2023 Shoreline Healthcare Center 4029 East Anaheim Street Long Beach, CA 90804

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the risk and benefits of the medication. The DON stated it was the responsibility of licensed nurses to ensure informed consent was obtained prior to administration of Resident 1's Celexa. Reviewed IC form with the DON, stated IC form was not signed by Resident 1 and her physician. The DON stated the form was incomplete per facility's P&P. During a concurrent interview and record review on 9/22/2023 at 4:04 pm with the DON, stated care plan for Celexa should be initiated. The DON stated, Celexa was ordered for Resident 1 on 10/23/2021. Reviewed care plan with DON stated Resident 1's care plan for Celexa was not initiated until 11/12/2021. During an interview on 9/27/2023 at 10:51 am with the Social Worker (SW), the SW stated, it was the responsibility of licensed nurses or social worker to get an informed consent for psychotropic medications including Celexa. SW stated the facility has 24-72 hours to get the informed consent signed by Resident 1. The SW stated, per facility's P&P, informed consent should be obtained and signed prior to administration of any psychotropic medications, including Celexa. During a review of the facility P&P titled Resident Rights dated 10/4/2016, the P&P indicated the resident has the right to be informed of your rights and of all rules and regulations governing resident conduct and responsibilities during your stay in the facility. The P&P indicated the resident has the right to participate in the development and implementation of your person-centered plan of care. During a review of the facility P&P titled Psychotropic Drug Use dated 8/2017, the P&P indicated, the SW and nursing will be responsible for initiating the resident's individualized, person-centered psychosocial plan of care, based on their comprehensive initial admission assessment. The P&P indicated an informed consent needs to be obtained prior to medication use. The P&P indicated, upon initiation of a new order for psychoactive medications, the Licensed Nurse shall complete the Verification of Informed Consent form prior to the initiation of the new medication. During a review of the facility P&P titled Care Planning dated 11/2007, the P&P indicated, a comprehensive care plan shall be developed for each resident. 055353 Page 2 of 2