Health inspection·August 2, 2022

The following reflects the findings of the California Department of Public Health during the Re-Certification survey from 7/11/22 to 7/18/22: Event ID: 8RQ011 Representing the Department, PCII # 27000 State Citation B was written F755 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- §483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits 9 out of 9 residents (Residents 11, 18, 23, 37, 116, 118, 133, 139, and 163) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. There was a total of 47 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications. The Controlled Drug Records (CDRs) for nine (9) random residents receiving PRN (meaning as-needed) controlled medications were requested for review during the survey. During an interview with the director of nursing (DON) on 7/13/22 at 3:07 p.m., she stated any time a resident requested for a PRN controlled medication, the nurse was to assess the resident's condition, remove the medication from the locked controlled drug compartment, sign out of the narcotic book (on the CDR), administer to the resident, document the administration on the MAR, then re-assess the resident for effectiveness after 45 to 60 minutes. a. Resident 23 had a physician's order, dated 7/1/21, for oxycodone (a potent controlled medication for moderate to severe pain) 10 milligrams (mg, unit of measurement), 1 tablet every 6 hours PRN moderate pain. During a concurrent interview and record review with the DON on 7/13/22 at 3:09 p.m., a review of Resident 23's CDR for oxycodone and the 7/2022 MAR reflected the nursing staff signed out of the CDR (meaning they removed the medication from the locked controlled medication compartment in the medication cart) but did not document the respective administration on the MAR: on 7/6/22 at 9 a.m., 7/8/22 at 9 a.m., and on 7/12/22 at 12 p.m. The DON verified this finding and acknowledged three (3) oxycodone tablets were not accounted. b. Resident 118 had a physician's order, dated 6/1/22, for tramadol (a controlled medication for pain) 100 mg, 1 tablet every 8 hours PRN pain. On 7/13/22 at 3:16 p.m., a review of Resident 118's CDR for tramadol and the July 2022 MAR with the DON indicated, on 7/4/22 at 11 a.m., the nursing staff removed a tablet of tramadol without documenting the administration on the MAR. She verified one tramadol tablet was unaccounted. c. Resident 37 had a physician's order, dated 3/11/22, for tramadol 50 mg 1 tablet every 4 hours PRN. On 7/13/22 at 3:19 p.m., a review of resident 37's CDR for tramadol 50 mg and the June 2022 MAR with the DON indicated the staff removed 1 tablet of tramadol on 6/11/22 at 5 a.m. but did not document the administration on the MAR. The DON verfied one tramadol tablet was unaccounted. d. Resident 11 had a physician's order, dated 4/2/22, for oxycodone-acetaminophen (Percocet, potent controlled medication for moderate to severe pain), 5-325 mg 1 tablet every 6 hours PRN pain. On 7/13/22 at 3:24 p.m., a review of Resident 11's CDR for Percocet 5/325 mg and the April 2022 MAR with the DON indicated the nursing staff signed out 4 tablets on: 4/3/22 at 3 p.m. and 10 p.m.; 4/4/22 at illegible time; and 4/11/22 at 4 a.m. However, none of these was documented on the MAR to indicate they were administered to the resident. The DON acknowledged 4 Percocet tablets were not accounted. e. Resident 133 had a physician's order, dated 5/7/22, for tramadol 50 mg 1 tablet every 6 hours PRN moderate pain. On 7/13/22 at 4:46 p.m., a review of Resident 133's CDR for tramadol and the June and July 2022 MARs with the DON indicated the nursing staff removed 10 tablets on: 6/25 at 10 p.m., 6/26 at 5 a.m., 6/27 at 5 a.m., 6/29 at 6 a.m., 6/30 at 5 a.m., 7/1 at 5 a.m., 7/5 at 2 p.m., 7/6 at 6 a.m., 7/7 at 6 a.m., and 7/8/22 at 11 a.m. However, none of these was documented on the MAR to indicate they were administered to the resident. The DON acknowledged 10 tramadol tablets for the resident was not accounted. f. Resident 116 had a physician's order, dated 1/25/22, for hydrocodone-acetaminophen (Norco, controlled medication for moderate to severe pain) 5-325 mg, 1 tablet every 6 hours PRN moderate to severe pain On 7/13/22 at 4:55 p.m., a review of Resident 116's CDR for Norco and the June and July 2022 MARs with the DON indicated the staff removed 13 tablets of Norco on: 6/15 at 8:30 a.m.; 6/24 at 9 a.m. and 6 p.m.; on 6/25 at "5" (no am or pm written); 6/26 at 8 p.m.; 6/28 at 9:18 a.m., at illegible time, "3:30", and "8:00"(no am or pm written); 6/29 at 2 a.m.; 7/1 at 3 p.m., 7/8 at 11 a.m.; and 7/9/22 at 9 a.m. None of these was documented on the MAR to indicate they were administered to the resident. The DON verified this finding and acknowledged 13 Norco tablets were not accounted for. During an interview with Resident 116 on 7/14/22 at 12:30 p.m., he stated he had pain on his knees, and the pain level was usually 9 out of 10 (severe pain). g. Resident 139 had a physician's order, dated 4/28/21, for Percocet 5-325 mg, 1 tablet every 4 hours PRN moderate to severe pain. On 7/13/22 at 4:59 p.m., a review of Resident 139's CDR for Percocet and the June and July MARs with the DON indicated the staff removed the following: On 6/28 at 12:45 a.m., 6/29 at 1 a.m., 6/30 at 12:12 a.m., 7/1 at 12 a.m., 7/2 at 2 a.m., 7/3 at 12 a.m., 7/4/24 at 12 a.m., 7/5 at 12:15 a.m., 7/6 at 12 a.m., and 7/7/22 at 1:30 (no a.m. or p.m. written). None of these was documented on the MAR to indicate they were given to the resident. The DON confirmed 10 Norco tablets for Resident 139 were unaccounted for. The CDR indicated these were removed by licensed vocational nurse (LVN) V. During an interview with Resident 139 on 7/14/22 at 9:14 a.m., she stated she had rheumatoid arthritis (chronic inflammatory disorder affecting many joints, including those in the hands and feet) but did not like to ask for pain medications often. She stated, "Sometimes it helps, and sometimes not" after the medication given to her. h. Resident 18 had a physician's order on 5/26/22 for lorazepam (Ativan, an anti-anxiety medication) 0.5 mg, 1 tablet at bedtime as needed for anxiety. On 7/2/22, the order was changed to 0.5 mg, 1 tablet every 8 hours PRN anxiety. On 7/13/22 at 5:03 p.m., a review of Resident 18's CDR for Ativan and the June and July MARs with the DON indicated the nursing removed 3 tablets without documenting the administration on the MAR. They were on: 6/14 at 9 p.m., 6/19 at 9 p.m., and 7/5 at 6:41 p.m. The DON confirmed 3 Ativan tablets for Resident 18 were not accounted for. The CDR indicated they were also removed by LVN V. i. Resident 163 had a physician's order, dated 6/7/22, for Norco 5-325 mg, 1 tablet every 6 hours PRN moderate to severe pain. On 7/13/22 at 5:08 p.m., a review of Resident 163's CDR for Norco and the July 2022 MAR with the DON indicated the nursing staff removed 2 tablets: on 7/7 at 12 a.m. and 7/10/22 at 3:30 a.m., without documenting these administrations on the MAR. The DON confirmed 2 Norco tablets for Resident 163 were not accounted for. During an interview on 7/13/22 at 5:14 p.m., the DON confirmed there was a total of 47 controlled medications removed from the medication carts but not documented as given for 9 out of 9 residents. She stated, "The nurse removes med but not documenting" on the MAR, but they were supposed to. She was asked to provide supporting evidence, such as in nursing progress notes, to demonstrate they were administered to the residents. During a follow-up interview on 7/14/22 at 11:40 a.m., the DON stated she looked into the nurses who failed to document the administrations and most of them were from the agency except registered nurse (RN) T, LVN V, the Infection Preventionist (IP) and a few staff who worked night shift. During an interview and record review with RN T on 7/14/22 at 11:45 a.m., she reviewed Resident 133's CDR and confirmed she removed the tramadol on 7/6 at 6 a.m. and 7/7 at 6 a.m.. She stated, "I admit I didn't document." She stated she was busy tending to many residents and forgot to document. She confirmed she was supposed to document each medication administration on the MAR. During a concurrent interview and record review with the IP on 7/14/22 at 11:55 a.m., she confirmed she did not document the administration of Resident 11's Percocet on 4/4/22 at around 1 p.m. She stated she must have forgotten to document, and she was supposed to document on the MAR to account for the medication. During an interview with LVN V on 7/14/22 at 4:28 p.m., she stated every time a controlled medication was removed from the medication cart, the nurse was to document the administration on the MAR to indicate it was given to the resident. She reviewed Resident 139's CDR and verified she did not document the Percocet administration ten days in a row; and 3 tablets of Ativan for Resident 18. She stated most of the time she was busy, distracted, and "I forget to document." As of the survey exit date on 7/18/22, there were no additional documentation provided to support the missing documentation. A review of the facility's policy and procedures titled "Medication Administration Orals" dated 11/2017, indicated: "Chart medication administration on Medication Administration Record immediately following each resident's medication administration." The facility's guidelines titled "Medication Pass Guidelines," dated 3/2000, indicated: "Record the name, dose, route, and time of medication on the Medication Administration Record." These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of the residents.