Health inspection·October 2, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents, when several psychotropic medications (used to treat mental illness) were not administered in accordance with the physician's orders, for one of three residents reviewed (Resident 2). This failure had the potential for Resident 2 to have adverse reactions and changes in behaviors related to not receiving the prescribed medications. Findings: On June 2, 2023, at 2:17 p.m., an unannounced visit was conducted at the facility to investigate an altercation involving Resident 2, who was hit in the head by her peer, but no injuries were incurred. On June 2, 2023, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a severe mental health condition where a person feels distrustful and suspicious of others) and schizoaffective disorder (persistent mental health condition characterized by delusions and hallucinations). On September 19, 2023, Resident 2's record was further reviewed. The Order Review Report, included the following physician's orders: - .clonazePAM (medication used to treat panic and anxiety, calms the brain and nerves) Oral (by mouth) Tablet 0.5 MG (milligram- unit of measurement) (Clonazepam) Give 1 (one) tablet by mouth at bedtime for PARANOID SCHIZOPHRENIA ., date ordered April 11, 2023; - .Paliperidone ER (extended release - medication used to treat schizophrenia and schizoaffective disorder) Oral Tablet Extended Release 24 Hour 3 MG (Paliperidone) Give 1 tablet by mouth in the morning for SCHIZOAFFECTIVE DISORDER .; date ordered April 11, 2023; and - .Haloperidol (medication used to treat mood disorders) Tablet 10 MG Give 1 tablet by mouth at bedtime for paranoia MB (manifested by) verbal aggression ., date ordered May 1, 2023. A review of Resident 2's Medication Administration Record, for the months of May and June 2023, indicated the following: - There were 21 days in May 2023 which indicated documentation to refer to progress notes for Page 1 of 2 055361 055361 10/02/2023 Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some clonazepam. Resident 2's Progress Notes, indicated clonazepam was not available to be administered and awaiting pharmacy delivery on May 15, 26, 27, 20, 21, 22, 23, 24, and 25, 2023 (nine days). There was no documented evidence a progress note was created on the other days (12 days) to reflect status of medication administration for clonazepam; - There were five days in May 2023 which indicated documentation to refer to progress notes for haloperidol. Resident 2's Progress Notes, indicated haloperidol was not available to be adminsitered and awaiting pharmacy delivery on May 22, 24, and 25, 2023 (three days). There was no documented evidence a progress note was created on the other days (two days) to reflect status of medication administration for haloperidol; - Paliperidone was documented to refer to progress notes on May 20 and 21, 2023. Resident 2's Progress Notes, indicated paliperidone was not available to be administered and awaiting pharmacy delivery on those days; and - Clonazepam was documented to refer to progress notes on June 1, 3, 4, 5, 6, 7, 9, 10, 14, 15, and 21, 2023 (11 days). Resident 2's Progress Notes, indicated clonazepam was not available to be administered and awaiting pharmacy delivery for 11 days. There was no documented evidence the physician was notified when the clonazepam, haloperidol, and paliperidone were not administered to Resident 2 for multiple days. There was no documented evidence the facility followed up with the pharmacy regarding the supply for clonazepam, haloperidol, and paliperidone when it was not available to be administered fo Resident 2. On September 25, 2023, at 2:30 p.m., during a follow up onsite visit, a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON confirmed the medications clonazepam, haloperidol, and paliperidone were not administered to Resident 2 on multiple days in May 2023, and the clonazepam was not administered to Resident 2 on multiple days in June 2023. The DON stated the facility's practice was to notify the physician anytime a medication was not given to a resident. The DON confirmed there was no documentation in the progress notes the physician was notified when the medications were not given to Resident 2, nor was there documentation the staff followed up with the pharmacy to obtain Resident 2's medications. The DON stated the physician should have been notified regarding the multiple instances the medications were not administered, and when the medications were not available from the pharmacy. The DON further stated she should have been notified by staff regarding their challenges in obtaining medication supplies from the pharmacy so she could assist them with the pharmacy issue. On September 27, 2023, the pharmacy delivery receipts and the pharmacy's delivery log were reviewed. There was no documented evidence the medication clonazepam for Resident 2 was delivered to the facility after April 17, 2023 until June 24, 2023. The facility's policy and procedure titled, Medication Administration - General Guidelines, dated August 1, 2010, was reviewed. The policy indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices . The facility's policy and procedure titled, Medication Orders, revised January 2018 was reviewed. The policy indicated, .The prescriber is contacted by nursing for direction when delivery of a medication will be delayed or the medication is not or will not be available . 055361 Page 2 of 2