Other·May 8, 2024

Stillwater Post Acute A Citation 42 C.F.R. §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 C.F.R. §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 22 C.C.R. § 72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/12/22, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation about nursing services and pharmaceutical services. On 7/20/22, the facility failed to protect a resident (Resident 1) from ingestion of unprescribed medications when Resident 1 removed Resident 2's medications from a bedside table where it was placed and left unattended by a licensed nurse (LN) 1, resulting in Resident 1's hospitalization. The facility failed to: 1. Ensure Resident 1's room environment remained free of accident hazards when LN 1 placed Resident 2's medications on an unsupervised bedside table, accessible to Resident 1, who has dementia and took and swallowed Resident 2's unsecured medication from the bedside table. 2. Provide adequate supervision of Resident 1 to prevent Resident 1 from consuming Resident 2's unsecured and unsupervised prescription medications that LN 1 placed on a bedside table in Residents' 1 and 2 shared room. 3. Ensure that Resident 1 received care and services safely in a safe and homelike environment by leaving prescription medication belonging to another resident unsecured on a bedside table. As a result of these facility failures, Resident 1 ingested medications that belonged to a different resident (Resident 2) which resulted in Resident 1 becoming unresponsive and requiring hospitalization for six days. Findings: An undated Resident Face Sheet for Resident 1 indicated that Resident 1 was admitted to the facility on 12/21/21 with diagnoses which included dementia (a loss of thinking, remembering, and reasoning which interfere with daily life), respiratory failure, diabetes, heart failure, hypertension, heart disease, obesity, low thyroid disease, high lipid levels, low potassium, nerve damage, arthritis, anxiety disorder, sleep apnea, and depression. On 9/13/22 a record review was conducted. A Minimum Data Set (MDS, an assessment tool) for Resident 1, dated 6/20/22, indicated Resident 1s MDS (an assessment tool), Section C, Brief Interview for Mental Status (BIMS, an assessment of cognitive function) was 5, indicating severely impaired cognition. A Nursing Progress Note, dated 7/20/22 at 10 A.M. and authored by LN 1, indicated Resident 1 was in a wheelchair inside his shared room. LN 1 documented she placed a medication cup with six medications [for Resident 2] on a bedside table while she assisted Resident 2 in the bathroom. LN 1 indicated Resident 1 wheeled himself to the bedside table and consumed his roommate's medication. LN 1 listed the ingested medications as: Potassium, Gabapentin, Depakote, furosemide, quetiapine, and primidone. LN 1 documented Resident 1 had already consumed his scheduled medications at 8:30 A.M. LN 1 listed the scheduled medications as: sertraline, metformin, amlodipine, oxybutynin, Vitamin B12, and Vitamin D. An Event Report, titled Medication Error, authored by LN 1 and dated 7/20/22, indicated Resident 1 had consumed his roommate's medications at 10 A.M., started becoming tired at 12 Noon, then lethargic and difficult to arouse at 1 P.M. LN 1 documented Resident 1 had a change in his level of consciousness and required a transfer to the hospital. A Vitals Report, dated 7/20/22 at 12:38 A.M., indicated Resident 1's heart rate (HR) was 85 beats per minute (bpm). At 8:38 A.M., Resident 1 's HR was 73 bpm. At 12 P.M., Resident 1's HR was 58 bpm. A Nursing Progress Note, dated 7/20/22 at 1:13 P.M., indicated Resident 1's HR was 56 bpm. LN 1 documented Resident 1 was sleeping and difficult to arouse. A General Acute Care Hospital (GACH) Physician (MD) Emergency Department Note, dated 7/20/22 at 3:39 P.M., indicated Resident 1 was brought in for accidental ingestion of another resident's pills. The MD documented Resident 1 ingested the pills around 10 A.M., and was then unarousable, so an ambulance was called. Per the MD, Resident 1 arrived lethargic and responds to painful stimuli, with a HR of 51. The MD documented concern that Resident 1 was developing signs of ineffective ventilation (losing the ability to breath independently) and so Resident 1 was intubated (insert a breathing tube through a person's mouth, then down into the airway). Resident 1 was sent from the Emergency Department to an Intensive Care Unit. A hospital document, titled Critical Care Physician's Note, dated 7/25/22 at 10:54 A.M., indicated Resident 1 was agitated, and required Zyprexa (a medication used to treat psychotic conditions). The MD indicated Resident 1 had an altered mental status and possible delirium (a serious change in mental abilities). A hospital Face sheet indicated Resident 1 was hospitalized for six days, returning to the skilled nursing facility on 7/26/22. Resident 1's diagnosis was Acute Respiratory Failure (a sudden inability to breath independently), altered mental status, accidental drug ingestion, diabetes, high blood pressure and anemia. A facility Consultant Pharmacist's review of the incident, dated 8/31/22, indicated on 7/20/2022, Resident 1 inadvertently received: 1. Potassium Chloride 10mEq (milliequivalents, a measurement. [medication to treat and prevent low blood potassium]) 2. Gabapentin 400mg (milligram, a measurement. [a medication for seizures or nerve pain]) 3. Depakote 500mg (a medication for seizures) 4. Furosemide 20mg (a medication to treat fluid retention and swelling) 5. Quetiapine 200mg (a medication used to treat bipolar disorder and schizophrenia) 6. Primidone 100mg (a medication used to treat seizure disorders) This was in addition to his ordered medications that were given at that time: 1. Sertraline 50mg (a medication to treat depression) 2. Metformin 1000mg (a medication to reduce blood sugar levels) 3. Amlodipine 5mg (a medication used to reduce blood pressure) 4. Oxybutynin 10mg (a medication for overactive bladder) 5. Vitamin B12 50mg (a vitamin) 6. Vitamin D 1000 IU (International Units, a measurement. [a vitamin]) Per the facility pharmacist consultant, the combination of 12 medications could potentially have adverse events. The pharmacist indicated that specifically, the Gabapentin, Depakote, Quetiapine, Primidone, and Sertraline could potentially cause CNS (central nervous system, the brain and spinal cord) side effects such as oversedation, confusion, and ataxia [impaired balance and coordination] especially when added to the Sertraline and Oxybutynin. On 9/12/22 at 11:28 A.M., an interview was conducted with the Administrator (Admin) and Director of Nursing (DON). During the interview, the Admin and DON stated the following events occurred on 7/20/22 when Resident 1, who resided with two other residents (Resident 2 and Resident 3), grabbed and ingested Resident 2's medication: Approximately 9:15 A.M., Licensed Nurse (LN) 1 administered medications to Resident 1. At approximately 10 A.M., LN 1 prepared medications for Resident 2. The medications were: potassium, gabapentin, Depakote, furosemide, quetiapine, and primidone. LN 1 then entered the room with the medications in hand. Resident 2 was in the restroom with the door closed. A bedside table was standing outside of the restroom door. LN 1 placed the medications for Resident 2 on the bedside table, then entered the restroom to assist Resident 2. LN 1 did not have full view of the medications while she assisted Resident 2 in the restroom. Resident 1 approached the bedside table and swallowed the medications intended for Resident 2 while LN 1 was assisting Resident 2. At approximately 10:15 A.M., LN 1 attempted to get Resident 1 to spit out medications and vomit medications without success. Also, at approximately 10:15 A.M., LN 1 texted the physician to inform him of the incident. LN 1 did not inform a charge nurse, DON, Assistant DON (ADON) or Quality Assurance nurse (QA, a nurse whose job focused on improvement processes) of the incident. At approximately 11 A.M. and again at 12 P.M., LN 1 checked vital signs and assessed Resident 1 for any side effects of the medications. At approximately 12 P.M., Certified Nursing Assistant (CNA) 1 informed LN 1 that Resident 1 was in bed, very sleepy. At approximately 12 P.M., LN 1 informed the DON of the incident, and LN 1 with the DON assessed Resident 1, found him in bed, sleeping and difficult to arouse. At 1:13 P.M., LN 1 and the DON called the physician. The physician ordered transfer to the hospital. At 2:40 P.M., Resident 1 transferred via ambulance to the hospital. On 9/12/22 at 11:28 A.M., an interview was conducted with the DON. The DON stated the nurse should have locked the medications in the medication cart before going into the bathroom. Per the DON, Resident 1 was impulsive, and the facility policy says to put the medications back in the med cart, label and secure it, then proceed to help the patient. The DON stated LN 1 had not made the right call at the moment. On 9/12/22 at 12:20 P.M., an interview was conducted with LN 1. LN 1 stated on 7/20/22, she had entered Resident 1's three-bed shared room with the medications for Resident 2. LN 1 stated she had placed the medications on the bedside table to assist Resident 2 in the restroom. LN 1 stated she had been focused on Resident 2 and could not see the medications placed to her side. LN 1 stated when she turned back, she saw Resident 1 placing the empty medication cup back on the table. LN 1 stated she should have put the medications in her pocket or locked it up in the medication cart. On 9/12/22 at 4:40 P.M., a concurrent interview and observation of Resident 1 was conducted in the facility activity room. Resident 1 was seated at a table painting a picture, conversing with other residents and staff. An attempt was made to interview Resident 1, he was unable to answer questions regarding his recent hospitalization. On 9/12/22 at 4:48 P.M., a telephone interview was conducted with CNA 1. CNA 1 stated she was assigned to provide care for Resident 1 on 7/20/22. CNA 1 stated she had been told by LN 1 to keep an eye on Resident 1. CNA 1 stated around lunchtime she had gone to Resident 1's room, and he was in a deep sleep. CNA 1 stated she tried to wake up Resident 1, but she was unable to. CNA 1 stated this was not normal for Resident 1, and she had reported her concerns to LN 1. CNA 1 stated Resident 1 had ended up going to the hospital. A facility policy, revised April 2019, and titled Storage of Medications, indicated, "The facility stores all drugs and biologicals in a safe, secure and orderly manner...1. Drugs and biologicals used in the facility are stored in locked compartments..." These policies were not implemented when Resident 1 was able to obtain and consume Resident 2's medications. Conclusion: These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.