Health inspection·January 11, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure one out of three residents (Resident 1) had written Informed Consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to help them decide if they want to authorize the given procedure or intervention) before they were administered a psychoactive medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Residents Affected - Few This failure had the potential to cause Resident 1 to take a psychoactive medication without knowledge of the medication ' s risks, benefits, and alternatives. A review of Resident 1's admission Record printed 3/21/24, indicated Resident 1 was admitted to the facility in 2022 with a diagnosis of Spastic Hemiplegia (a nerve and muscle condition that results in the muscles on one side of the body being in a constant state of contraction). The record indicated Resident 1 was their own Responsible Party (health care decision maker). During a concurrent interview and record review on 3/21/24 at 3:59 p.m., with Registered Nurse (RN) 1, Resident 1 ' s Doctors Orders, dated November through December 2023 and Informed Consents, were reviewed. RN 1 confirmed Resident 1 had multiple doctor ' s orders for Ativan (a psychoactive medication used to treat anxiety) that started on 11/28/2023. RN 1 stated they could not find Resident 1 ' s written Informed Consent for Ativan. RN 1 stated Resident 1 should have had an informed consent for Ativan. RN 1 stated Informed Consent for Ativan was important so Resident 1 could have known the medication risks, benefits, and alternatives and could have had the right to refuse the medication. During a concurrent interview and record review on 3/26/24 at 1:14 p.m., with Regional Director of Staff Development (RDSD), Residents 1 ' s Informed Consents were reviewed. RDSD stated nurses were supposed to ensure residents had Informed Consent for Ativan signed by the resident or their responsible party and the doctor before starting the medication. RDSD stated Resident 1 did not have written Informed Consent for Ativan. During an interview on 4/17/24, at 2:58 p.m., with Director of Nursing (DON), DON stated their policy for all psychoactive medications was to get informed consent before starting the medication. DON stated the doctor was responsible to get the Informed Consent, explain the medication risks, benefits, alternatives, and the right to refuse, to the resident or responsible party. DON stated the nurse was responsible to verify the Informed Consent was done. DON stated Informed Consent was important because Residents are entitled to know the risks and benefits of a medication before they take it, especially a psychoactive medication. DON stated when Informed Consent was not obtained, residents may not have been aware of the medication risks, benefits and alternatives. Page 1 of 2 055876 055876 01/11/2024 Princeton Manor Healthcare Center, LLC 2124 57th Avenue Oakland, CA 94621

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review on Resident 1 ' s History and Physical, (H&P) dated 12/5/22, the H&P indicated the resident had capacity (the ability to utilize information about an illness and proposed treatment options to make a choice that is fitting with one's own values and preferences). During a review of Resident 1 ' s Order Summary Report, dated 3/21/24, the report indicated Resident 1 had Physician ' s orders for Lorazepam (a generic name for Ativan) and Ativan. The report indicated Resident 1 had a Physician ' s Order for Lorazepam oral tablet 0.5mg (milligrams) . Give 1 tablet by mouth every 6 hours as needed for anxiety, dated 11/28/23. The report indicated Resident 1 had a Physician ' s Order for Ativan oral tablet 0.5mg . Give 2 tablet by mouth every 6 hours as needed for anxiety, dated 12/15/23. The report indicated Resident 1 had a Physician ' s Order for Ativan Oral Tablet 0.5mg . Give 2 tablet by mouth every 6 hours as needed for anxiety, dated 12/19/23. During a review of Resident 1 ' s Medication Administration Record (MAR), dated December 2023, the MAR indicated Resident 1 was given Ativan and Lorazepam nineteen times in December 2023. The MAR indicated Resident 1 received Lorazepam oral tablet 0.5mg .1 tablet, one time each day on 12/1/23, 12/2/23, 12/5/23 through 12/8/23, 12/11/23, 12/13/23, and 12/15/23 and two times each day on 12/12/23 and 12/14/23. The MAR indicated Resident 1 received Ativan oral tablet 0.5mg . 2 tablet, one time each day on 12/16/23, 12/22/23, and 12/25/23, and three times on 12/24/23. During a review of the facility ' s policy and procedure (P&P) titled, Informed Consent, revised December 2020, the P&P indicated, The ordering physician must obtain informed consent before the facility can administer new orders (or increased dosages) for psychoactive medication . The P&P indicated Physician documentation of informed consent should contain the date and who gave informed consent (Resident of surrogate decisionmaker). The P&P indicated Before administering the first dose or first increased dose of psychoactive medications . the licensed nurse will confirm that the physician obtained informed consent and will document the verification in the Resident ' s medical record. 055876 Page 2 of 2