Health inspection·November 1, 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 administer the medication Tramadol 50 mg (medication used to help relieve moderate to moderately severe pain) as per physician ' s order for one (Resident 1) of three sampled residents. Residents Affected - Few This failure resulted in Resident 1 receiving a double dose of medication within 12 hours and placed Resident 1 ' s health and safety at risk. Findings: During a review of Resident 1 ' s admission record, printed on 11/1/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a review of Resident 1 ' s physicians orders dated 8/15/23, the physician orders indicated to administer Tramadol HCL oral tablet 50 mg, 1 tablet every 12 hours as needed for pain. During a review of Resident 1 ' s Antibiotic and Controlled Drug Record, dated 8/30/23, the controlled drug record indicated on 9/20/23, Tramadol was taken out of the medication cart at 10:15 p.m. and signed by licensed nurse. The controlled drug record also indicated Tramadol was taken out of the medication cart at 2:21 am on 9/21/23 and signed by licensed nurse. During a concurrent interview and record review on 11/1/23, at 1:08 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Medication administration record (MAR), for [DATE] was reviewed. LVN 1 stated that the MAR indicated Tramadol was administered on 9/21/23 at 2.16 a.m. LVN 1 stated there was no record of Tramadol administered at 10:15 pm on 9/20/23 in the electronic health record. During an interview on 11/1/23, at 2:22 p.m. with Registered Nurse (RN) 1, RN 1 stated on 9/20/23 she administered the medication Tramadol 50 mg orally to Resident 1 at 10:15 pm. RN 1 stated after administering the medication she forgot to click the save in electronic health record and the medication administration was not registered in the system accurately. RN 1 stated this allowed the night shift nurse to administer medication again before it was due. RN 1 stated it is very important to document medication administration correctly to prevent residents getting double doses and can be dangerous. During an interview on 11/1/23 at 2:35 p.m. with Director of Nursing (DON), DON stated it is critical to accurately document medication administration as it is the proof that the medication was given and a way of communication to the other nurses. DON stated when medication administration is not documented correctly there is a high risk for medication error with possibility to cause adverse Page 1 of 2 055715 055715 11/01/2023 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0760 effects and permanent complications. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s undated policy and procedure (P&P) titled, Medication administration, the P&P indicated, To administer oral medication in an organized, accurate and safe manner .Chart medication administration on Medication Administration Record immediately following each resident ' s medication administration. Residents Affected - Few 055715 Page 2 of 2