Health inspection·August 31, 2023

F 0760 Ensure that residents are free from significant medication errors. 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 three medications were administered to the appropriate resident for one of three residents (Resident 1). This failure had the potential to affect Resident 1's respiratory function and overall health and safety. Residents Affected - Few Finding: An abbreviated survey was conducted on August 4, 2023, at 11:20 AM to investigate a complaint related to quality of care. During a review of Resident 1's clinical record, the face sheet indicated Resident 1 was admitted on [DATE], with diagnoses, which included Myocardial Infarction (Heart attack), Cerebral Vascular Accident (an interruption in the flow of blood to cells in the brain). During review of the clinical record for Resident 1, the Incident Note dated July 30, 2023, at 2:08 pm by the Director of Nursing (DON) indicated, Notified by RN regarding administering another residents' medications (Hydromorphone 4mg (a powerful pain killer), Cymbalta 60mg (used for treatment of depression and anxiety), and baclofen 20mg (a muscle relaxant). During an interview and concurrent record review of Resident 1's clinical records with the DON on August 4,2023, at 1:44 PM, DON stated, (Resident 1) was mistakenly given medication that belonged to another resident. She stated Licensed Vocational Nurse (LVN 1) misidentified the patient and gave him another residents medications. LVN1 came to me and notified me then we called the MD and per his orders started hourly vitals and continued observations on him for 48 hours. When asked if the patients had any negative side effects of the incorrect medications she stated, No he was fine he was a little sleepy, but his vital signs were normal, and he was okay we documented all our vitals and observations. The DON further stated, the staff are expected that it is the right med, right route, right dose, right indication, right patient. They can identify the patient by room number and patient picture and name in Point Click Care (PCC) (an Electronic Health record used by Skilled nursing facilities) some patients also have name tags/ bracelets. When asked if LVN 1 followed proper process for administering medication she stated, No she did not, she would have been able to tell the patients was the wrong one if she had verified with the picture on PCC, or if she was still unsure ask another nurse familiar with the patient. When asked what could happen if patients are given the wrong medication she stated, A lot of medication interactions could happen if the patients are given wrong medications, it depends on the Page 1 of 2 055557 055557 08/31/2023 Creekside Post Acute 35253 Avenue H Yucaipa, CA 92399

F 0760 patient and the drug given. Level of Harm - Minimal harm or potential for actual harm During an interview on August 22, 2023, at 11:45am with LVN 1, LVN 1 stated, I was preparing medication for another patient and this patient had a similar name and he was out of the room. I ended up giving the wrong patient the medications. As soon as I realized I ran to the DON and notified her. LVN 1 Further stated,I could have given him something he was allergic to, I could have depressed his respirations, I could have caused a lot of problems. Residents Affected - Few During a review of the facility policy and procedure titled, Administering medications undated, indicated, 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identification include: a. Checking identification band b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personal. 10. Individual administering medications checks the label THREE times to verify the right resident, right medication, right dosage, right time, right method or administration before giving the medication. 055557 Page 2 of 2