Health inspection·June 2, 2022

The following reflects the findings of the California Department of Public Health during the Re-Certification survey from 5/16/2022 to 5/20/2022: Event ID: FJRS11 Representing the Department: HFEN, 42819 State Citation B was written F760 §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. The facility failed to ensure Resident 396 was free of a significant medication error when Resident 396's Eliquis (a prescription medicine used as a prophylaxis (preventive treatment) against stroke with atrial fibrillation (AF, is an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) was not administered as ordered by the physician. This resulted in Resident 396 not receiving 18 doses of Eliquis while in the facility. This deficient practice could increase Resident 396's risk of developing a blood clot due to diagnosis of AF and history of cerebrovascular accident (CVA, the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain). Review of Resident 396's clinical record, resident was admitted to the facility on 4/25/2022, with diagnoses including, hemiplegia following cerebral infarction left nondominant side (paralysis of partial or total body function on one side of the body), dysphagia following cerebral infarction (difficulty swallowing), paroxysmal atrial fibrillation, heart failure (occurs when the heart muscle does not pump blood as well as it should). Review of Resident 396's physician's order on admission, dated 4/25/2022, indicated Eliquis 2.5 mg tablet, give 1 tab via GT (gastrostomy tube, a tube inserted through the wall of the abdomen directly into the stomach) twice daily for atrial fibrillation. Indicated on the time code column to be given at 9:00 a.m., which is once a day only. Review of Resident 396's medication administration record (MAR, a medical record documenting administered doses of medication) for April 2022 and May 2022, there was no record indicating the nursing staff administered the Eliquis twice a day from 4/26/22 until 5/13/22. During a concurrent record review and interview with the director of nursing (DON) on 5/19/2022 at 11:00 a.m., regarding concern with the missed dose of Eliquis from 4/26/2022 to 5/13/2022. Also informed the DON that the indicated administration time on the MAR was 9:00 a.m., instead of twice daily which was indicated on the physician's order. DON stated she was not sure what happened. During a concurrent interview and record review with registered nurse J on 5/19/2022 at 3:00 p.m., RN J stated she reviewed the admission physician's order for Resident 396. RN J confirmed that the order for Eliquis 2.5 mg tablet is to give 1 tablet via GT twice daily for Atrial Fibrillation. RN acknowledged that the indicated administration time was 9:00 a.m., which was only once a day. RN stated that it should have been 9:00 a.m. and 5:00 p.m. RN further stated it should have been caught during the review of the admission physician's order. During an interview with the pharmacy consultant on 5/20/2022 at 8:09 a.m., PC stated the manufacturer's recommendation is twice a day for diagnosis of arial fibrillation. PC further stated not receiving the full dose increases Resident 396's risk of CVA. During an interview with Resident 396's primary care physician on 5/20/2022 at 8:28 a.m., she stated she was not aware about the 18 doses of Eliquis that was missed. PCP further stated Resident 396 would not be at a therapeutic (a drug or treatment for an illness or condition) level having missed that many doses. PCP stated this would increase the risk of clot formation and puts the resident at a greater risk for stroke due to diagnosis of atrial fibrillation and history of CVA. During a follow-up interview with the DON on 5/20/2022, at 11:45 a.m., DON stated nurses should follow doctor's order and clarify if not clear. DON stated that the admission coordinator (AC) entered the admission orders, after that the admitting charge nurse would review the orders. DON confirmed that the 9 a.m. was clicked into the MAR but not the evening dose. DON further stated it is a medication error and not acceptable to have missed 18 doses of medication. Review of facility's policy, "Administering Medications," indicated, "Medications are administered in accordance with prescriber orders including any required time frame...The individual administering the medication checks the label three times to verify the right resident, right medication, right time and right method of administration before giving the medication." The facility failed to ensure Resident 396 was free of a significant medication error when Resident 396's Eliquis (a prescription medicine used as a prophylaxis (preventive treatment) against stroke with atrial fibrillation (AF, is an irregular and often very rapid heart rhythm that can lead to blood clots in the heart) was not administered as ordered by the physician. This resulted in Resident 396 not receiving 18 doses of Eliquis while in the facility. This violation had a direct or immediate relationship to the health, safety, or security of the resident.