Health inspection·May 5, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview and record review, the facility failed to supply Tramadol (generic name; a controlled drug used to treat moderate to severe pain) to one of three residents (Resident 1) as ordered for 57 days since Resident 1's admission to the facility. This failure had the potential to cause Resident 1 discomfort, pain, and inability to sleep. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March of 2023 with diagnoses including urinary tract infection (infection which affects the passageway of urine). A review of Resident 1's Hospital Discharge summary, dated [DATE], indicated Tramadol 50 mg (milligrams, a unit of measurement) four tablets was part of the 13 medications ordered by the provider for the skilled nursing facility. A review of Resident 1's Order Summary Report indicated Resident 1 had orders for Tramadol HCL (hydrochloride) Oral tablet 50 mg. Give 1 tablet by mouth every 6 hours as needed for moderate-severe pain, dated 3/9/2023. A review of Resident 1's Nursing Progress Note, dated 3/9/2023 at 8:01 p.m., indicated Resident c/o (complain of) pain to the left upper arm with a pain scale: 8/10 (numeric pain scale; 10 being the highest number for the worst pain). Notified [name of medical doctor; MD 1] with T.O. [telephone order] Tramadol 50 mg, 1 tab po [per os; by mouth] q [every] 6 hours for moderate-severe pain . A review of Resident 1's Medication Order, dated 3/9/2023 at 7:57 p.m., indicated MD 1 ordered Tramadol 50 mg via telephone order. A review of Resident 1's Nursing Progress notes indicated: 4/23/23 at 2:28 p.m.: Placed call to [name of pharmacy], regarding clarification on resident's [Resident 1] Tramadol delivery status .Medication was never delivered due to invalid order, no quantity was listed on order by primary provider, MD notified. 4/29/2023 at 10:27 a.m.: Placed a call to . regarding the delivery status for Tramadol .there is currently no E-script [electronic medication prescription signed by a medical provider] sent at this Page 1 of 3 055481 055481 05/05/2023 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0755 time. MD notified. Level of Harm - Minimal harm or potential for actual harm 4/30/2023 at 1:01 p.m.: Placed a call to .regarding the delivery status for Tramadol .there is currently no E-script sent at this time. MD notified. Residents Affected - Few A review of Resident 1's Medication Administration Record for the months of March, April, May 2023 indicated Tramadol had not been given to Resident 1 since her admission in March of 2023. A review of Resident 1's History & Physical, dated 5/2/2023 at 10:09 a.m., by MD 2 indicated Tramadol was one of the six medications prescribed for Resident 1. During a concurrent observation, interview, and record review on 5/5/2023 at 1:25 p.m. with Licensed Nurse 1 (LN 1), the narcotic medication cart was reviewed with LN 1. The cart contained six packs of narcotic medications for various residents and no Tramadol packs for Resident 1. LN 1 stated she called both the pharmacy and MD 1 regarding the medication order for Tramadol on the following dates: 4/21, 4/29, and 4/30. LN 1 stated there was no Tramadol pack for Resident 1 but there were Tramadol packs for Resident 2 and Resident 3. During an interview with Resident 1 on 5/5/2023 at 3 p.m., Resident 1 stated that she could not sleep at night due to pain in her legs. Resident 1 stated that she had restless leg syndrome (a long term disorder that causes a strong urge to move one's legs, which is aching, tingling, or crawling in nature). Resident 1 also stated that she took Tramadol regularly at home but did not know if the staff had given her Tramadol for her pain. During a concurrent interview with LN 2 on 5/5/23 at 3:48 p.m., LN 2 stated that Tramadol was ordered for Resident 1 for moderate to severe pain, but Resident 1 had to ask for pain medication. During an interview with the Administrator (ADM) on 5/5/23 at 3:52 p.m., the ADM stated MD 1 was a very busy physician. The ADM stated the Medical Director (MD 3) was supposed to write the e-script when they did not get a response from MD 1. During an interview with Pharmacy Director (PD) of [name of contracted Pharmacy] on 5/8/23 at 9:38 a.m., PD stated that Resident 1 was admitted with a Tramadol order for pain. PD also stated that pharmacy was not able to supply Tramadol for Resident 1 because they had not received the prescriber's valid prescription for Tramadol. The facility faxed an invalid prescription to the pharmacy on 4/11/2023.The PD stated there had been various correspondence and phone calls regarding the delivery of Tramadol and phone calls to the prescriber. PD also stated that nurses could have escalated the delivery of this medicine if they requested the pharmacist to help them call the MD for the signature. The PD stated the request was not made by the nurses. When the nurses called, they only asked if the Tramadol had been delivered. A review of a facility policy titled, Medication Orders, revised on 5/15/2018, indicated, Before a controlled drug can be dispensed, the pharmacy must be in receipt of a valid prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled medication .if the prescriber issues a chart order, he/she must also provide the pharmacy with a valid prescription. A review of a facility policy titled, Medication Ordering and Receiving from Pharmacy, revised 5/15/2018, indicated, Controlled substances prescribed for a specific resident are delivered to the 055481 Page 2 of 3 055481 05/05/2023 Vienna Nursing and Rehabilitation Center 800 So. Ham Lane Lodi, CA 95242

F 0755 facility only if a valid prescription has been received by the pharmacy prior to dispensing. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055481 Page 3 of 3