Health inspection·April 18, 2024

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 interviews and record review, the facility failed to ensure Registered Nurse 1 (RN 1) transcribed a physician order accurately and administered the prescribed dose of lisinopril-hydrochlorothiazide (a combination of medication used to treat hypertension) as ordered by the physician for one of three sampled residents (Resident 1) between 3/30/2024 to 3/31/2024 and 4/1/2024 to 4/16/2024. Resident 1 was administered a total of 13 incorrect doses of lisinopril-hydrochlorothiazide. Residents Affected - Some This deficient practice placed Resident 1 at risk for serious health complications as a result of being administered lisinopril-hydrochlorothiazide when the blood pressure (BP - pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) was less than 140/80 mmHg. This can lead to low blood pressure, lightheadedness, dizziness, and weakness. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), acute respiratory failure (occurs when the lungs cannot release enough oxygen into your blood), hypertension (high blood pressure), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 1's History and Physical (H&P- a term used to describe a physician's examination of a resident) dated 3/29/2024 indicated Resident 1 can make needs known but cannot make medical decisions. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 4/4/2024, indicated Resident 2 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated Resident 1 required supervision by staff for eating. Resident 1 is dependent on staff for oral hygiene, toileting hygiene and personal hygiene. A review of Resident 1's Telephone Physician Order Communication Note, obtained by RN 1, dated 3/29/2024 timed at 10:56 p.m. indicated to administer lisinopril-hydrochlorothiazide tablet 20-25 milligrams (mg- unit of measure) give 12.5 mg by mouth one time a day for hypertension give only if BP is greater than 140/80 mmHg. Upon further review of Resident 1's Telephone Physician Order Communication Note, obtained by RN 1, dated 3/29/2024 timed at 10:56 p.m. indicated the above order was Page 1 of 3 056253 056253 04/18/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0760 discontinued on 3/29/2024 at 10:56 p.m. due to an updated dose. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1's updated Telephone Physician Order Communication Note transcribed by RN 1, dated 3/29/2024 timed at 10:56 p.m. indicated a new order to administer lisinopril-hydrochlorothiazide tablet 20-12.5 mg, give one tablet by mouth one time a day for hypertension, hold if vital signs (measurements of the body's most basic functions) shows blood pressure equals (=) systolic blood pressure (SBP- first number, indicates how much pressure your blood is exerting against your artery walls when the heart contracts) is less than (<) 140/80. Residents Affected - Some A review of Resident 1's Medication Administration Record (MAR - a report detailing the medications administered to a resident) from 3/30/2024 to 3/31/2024 and 4/1/2024 to 4/16/2024 indicated to administer lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg one tablet by mouth one time a day for hypertension, hold if vital signs show blood pressure = SBP < 140/80. Further review of Resident 1's MAR indicated Resident 1 was administered lisinopril-hydrochlorothiazide oral Tablet 20-12.5 mg on: 3/30/2024 at 9:00 a.m. BP 130/60 3/31/2024 at 9:00 a.m. BP 129/66 4/1/2024 at 9:00 a.m. BP 130/64 4/2/2024 at 9:00 a.m. BP 134/52 4/3/2024 at 9:00 a.m. BP 128/66 4/4/2024 at 9:00 a.m. BP 106/74 4/6/2024 at 9:00 a.m. BP 112/63 4/7/2024 at 9:00 a.m. BP 123/55 4/8/2024 at 9:00 a.m. BP 123/50 4/13/2024 at 9:00 a.m. BP 138/88 4/14/2024 at 9:00 a.m. BP 116/67 4/15/2024 at 9:00 a.m. BP 120/82 4/16/2024 at 9:00 a.m. BP 128/60 During an interview with RN 1 on 4/18/2024 at 1:15 p.m., RN 1 stated that she did speak with Resident 1's Medical Doctor (MD) on 3/29/2024 to clarify the physician order regarding lisinopril-hydrochlorothiazide 20-25 mg. RN 1 stated Resident 1's MD ordered to administer lisinopril-hydrochlorothiazide oral tablet 20-12.5 mg, give 1 tablet by mouth one time a day for hypertension and hold if vital signs show systolic blood pressure greater than 140/80 mmHg. RN 1 stated that when she transcribed the physician's order, she made a mistake by using < (less than) symbol when she documented Resident 1's MD order. RN 1 stated she should have transcribed and documented > (greater than symbol) 056253 Page 2 of 3 056253 04/18/2024 Berkley Post-Acute 6600 Sepulveda Blvd Van Nuys, CA 91411

F 0760 140/80 mmHg instead. Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing (DON) on 4/18/2024 at 3:00 p.m., the DON stated that the correct process when receiving a telephone order with the medical doctor is to read back the physician's order to the medical doctor or provider to ensure there are no discrepancy or errors in the telephone order. The DON further stated RN 1 should not have used a symbol when receiving a physician order by the telephone. Residents Affected - Some A review of the facility's policy and procedure titled Physician's Orders dated 9/2020 indicated It is the policy of the facility to transcribe physician's order either by phone or verbal for all prescription, non-prescription medications .To have a complete order the following information must be included: 1. The individual's full name 2. The date of the order 3. Name of the medication, and other orders. 4. Dosage and administration information 5. Route of administration 6. Physician's signature The staff is responsible to query and verify with the doctor the order for accuracy. 056253 Page 3 of 3