Health inspection·August 17, 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 interview and record review, the facility failed to provide pharmaceutical services to meet the needs of one of 3 residents (Resident 1) when Resident 1 did not receive her Hydromorphone (a potent controlled medication for pain) Hydrochloride (HCL - acid salt mixed in the medication) in timely manner as prescribed by the physician. This failure had the potential to result in unnecessary pain. Findings: Review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility with diagnoses including aftercare following joint replacement surgery, presence of left artificial knee joint, other chronic pain and dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling). Review of Resident 1's clinical record titled, Order Summary Report, dated 05/17/2023, indicated, HYDROmorphone HCL Oral Tablet 2 MG (milligrams - unit of measurement) Give 4 mg by mouth every 3 hours as needed for severe pain 7-10. The medication was ordered on 5/14/2023. Review of Resident 1's admission Note, dated 5/14/2023, it indicated Resident 1 was admitted on [DATE] at 1:49 p.m. Review of Resident 1's clinical record titled, Progress Notes, dated 5/15/2023, it indicated Resident 1 complained of pain at 12 midnight, but her medications were not delivered yet. The licensed vocational nurse A (LVN A) assigned to Resident 1, called the facility's pharmacy to obtain the Cubex code (authorization provided by the pharmacist) to get the Hydromorphone HCL from the Cubex (automated dispensing cabinet for medication supply) machine. When LVN A spoke to someone at the facility's pharmacy, he was told they were on lunch break. LVN A tried to call after 10 minutes but nobody answered his call. Further review of the progress note indicated Resident 1 called 911 at around 2:30 a.m. due to severe pain and medications were still not available. During a phone interview with LVN A on 8/17/2023 at 1:50 p.m., LVN A stated when Resident 1 complained of pain, he tried to offer Tylenol (Brand name of acetaminophen - non-narcotic pain reliever) but Resident 1 refused. LVN A further stated he called the facility's pharmacy several times to get the Cubex code but phamacy staff were on their lunch break. LVN A confirmed Resident 1 called 911 due to severe pain. LVN A stated he finally got the Cubex code at 3:00 a.m. Page 1 of 2 055517 055517 08/17/2023 Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a follow up phone interview with DON on 8/21/2023 at 1:54 p.m., DON stated the delivery of medications for residents admitted in the afternoon, would be the following day at 6 a.m. During a phone interview with the pharmacist on 8/21/2023 at 2:40 p.m., pharmacist confirmed nurses should call the facility's pharmacy to obtain a Cubex code to get pain medication from the Cubex machine. The pharmacist stated the ideal response time for the pharmacy to provide the Cubex code should be 3-5 minutes. Pharmacist further stated, there were times it would take about 20 minutes when nurses called the wrong extension number. Pharmacist confirmed three hours wait time to obtain the Cubex code was not acceptable. During a review of the Pharmacy's policy and procedure titled, MEDICATION ORDERING AND RECEIVING FROM PHARMACY, dated January 2022, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis. During a review of the Pharmacy's policy and procedure titled, Accurate Use and Storage of Drugs in Automated Drug Delivery System (ADDS), dated 07/01/19, indicated, .to establish guidelines for medication order review, dispensing, and authorized access to medications from automated drug delivery systems to ensure patient safety. Access to automated drug delivery systems was granted only to licensed facility nursing staff and was assigned by the Director of Nursing. Medication shall be retrieved from the automated drug delivery systems only upon authorization by a .pharmacist. 055517 Page 2 of 2