Health inspection·December 19, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet professional standards of quality, for one of three sampled residents (Resident 1) when Resident 1 did not have duloxetine (medication for depression) available for three days and licensed nurses did not follow up with pharmacy to check the order status. Residents Affected - Few This failure placed Resident 1 at risk to experience anxiety, irritability, difficulty in sleeping, and possibly nightmares. Findings: During on observation on [DATE] at 5:33 p.m. in Resident 1 ' s room, Resident 1 was seated in her wheelchair. Resident 1 stated she has not received duloxetine for three days because the facility ran out of her medication. Resident 1 stated the medication was working well and since she stopped taking the medication, she experienced nightmares. During a review of Resident 1's Face Sheet (FS, a document with demographic, personal and medical information) undated, the FS indicated Resident 1 had diagnoses which included anxiety and major depression. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Physician Order(PO) dated [DATE], the PO indicated, . 20 MG [milligram-unit of measure] (Duloxetine) Give 2 capsule by mouth two times a day for irritability, general discontent . During a concurrent interview and record review on [DATE] at 6:08 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Medication Administration Record (MAR) dated 12/2023 was reviewed. The MAR indicated, duloxetine was unavailable from [DATE] - [DATE]. LVN 1 stated there was no documentation in Resident 1 ' s clinical record to indicate that pharmacy was contacted to ensure the medication order went through. LVN 1 stated if pharmacy was notified, they would have received the medication the same day. LVN 1 stated the Licensed Nurse (LN) should have ensured the medication was ordered timely to prevent the medication from running out. Page 1 of 2 055839 055839 12/19/2023 San Luis Care Center 709 N Street Newman, CA 95360

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 7:06 p.m. with LVN 2, LVN 2 stated she was currently the assigned nurse for Resident 1. LVN 2 stated she did not administer duloxetine because it was unavailable. LVN 2 stated she did not call pharmacy to check on the order status but should have. LVN 2 stated Resident 1 should have received the medication to prevent her from becoming irritable. During a telephone interview on [DATE] at 9:33 a.m., with Pharmacy Consultant (PC), PC stated the side effect of missing doses of duloxetine was potentially feeling depressed and irritable. PC stated the facility should have ordered the medication ahead of time to prevent missing doses. During a telephone interview on [DATE] at 10:00 a.m. with LVN 3, LVN 3 stated the prescription for duloxetine was expired and needed to be re-ordered. LVN 3 stated LN ' s should re-order medication when there is three day supply left. LVN 3 stated if there was a follow up call to pharmacy it would be documented in the nurses notes. During a concurrent telephone interview and record review on [DATE] at 11:30 a.m. with the Director of Nursing (DON), the facility policy titled Reordering, Changing, and Discontinuing Orders dated [DATE] was reviewed. The policy indicated, .Facility staff should review the transmitted re-orders for status and potential issues and Pharmacy response . The DON stated when medication supply is less than three days the LN should call the physician and pharmacy to follow up to prevent delay. The DON stated LN ' s should document their conversation to ensure follow up was done. During a review of MedlinePlus Professional Reference titled, Duloxetine dated [DATE], (found at https://medlineplus.gov/druginfo/meds/a604030.html#how) indicated, .If you suddenly stop taking duloxetine, you may experience withdrawal symptoms such as nausea; vomiting; diarrhea; anxiety; dizziness; tiredness; headache; pain, burning, numbness, or tingling in the hands or feet; irritability; difficulty falling asleep or staying asleep; sweating; and nightmares . 055839 Page 2 of 2