Health inspection·July 25, 2023

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was administered buspirone (treats anxiety) with adequate monitoring of adverse effects from the medication. Residents Affected - Few This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder (excessive and overwhelming worry about ordinary issues like work, money and family) and anoxic brain damage (brain is deprived of oxygen, symptoms include changes in sleep pattern, trouble speaking and swallowing). Review of Resident 1's Order Summary Report for September 2022 indicated an order for Resident 1 to receive buspirone 5 milligrams via PEG (percutaneous endoscopic gastrostomy, a flexible tube is placed through the abdominal wall into the stomach to receive nutrition and/or medication) two times daily for agitation, restlessness and falling tendency. During a concurrent interview and review of Medication Administration Record (MAR) for August 2022 with Assistant Director of Nursing (ADON) on 7/25/23 at 11:59 a.m., ADON stated, Resident 1's MAR indicated monitoring for antipsychotic (medication that treats psychosis, a severe mental illness) adverse effects was done. ADON stated, Resident 1 was given buspirone, which was an anti anxiety and not an antipsychotic, and had different adverse effects. Review of Resident 1's Medication Administration Record (MAR) for September 2022 indicated Resident 1 was monitored for the presence of tardive dyskinesia (facial tongue movement), cognitive impairment (decreased mental status), akathisia (inability to sit still), parkinsonism (tremors, rigidity, drooling). According to Dailymed, a nationally-recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration, buspirone adverse events include; dizziness, insomnia, nervousness, drowsiness, lightheadedness, nausea, headache and fatigue. Review of the facility's policy and procedure titled Psychotropic Medication Management last revised 10/24/17 indicated, Medication effects will be monitored and documented on the medication Page 1 of 2 055885 055885 07/25/2023 Country Drive Post Acute 2500 Country Drive Fremont, CA 94536

F 0757 administration record, to include target behavior monitoring, and monitoring for adverse effects when the medications are used. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055885 Page 2 of 2