Other·December 23, 2022

Health and Safety Code 1424(f) (1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2) "Willful material falsification," as used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the resident or the care or services provided. (3) "Willful material omission," as used in this section, means the willful failure to record any untoward event that has affected the health, safety, or security of the specific patient, and that was omitted with the knowledge that the records falsely reflect the condition of the resident or the care or services provided. On 8/9/22, at 8:36 AM, an unannounced visit was conducted at the facility to investigate a complaint regarding the falsification of blood pressure and blood sugar measurements in residents' health records. Based on observation, interview, and record review, the facility failed to ensure accurate documentation of blood pressure (BP- force of blood against the arteries) and blood sugar (BS - amount of sugar in the blood) measurements in the medical record for 11 of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11) when two nurses willfully documented false information. This failure had the potential for using inaccurate information to make medical decisions when assessing residents' health, and dosing or administering blood pressure and/or blood sugar medications, which could adversely affect the residents' health conditions. Findings: During a review of Resident 1's "Admission Record," (AR) dated 9/10/22, the "AR" indicated, Resident 1, an 84-year-old female, was admitted to the facility on 12/18/18, with a diagnosis of diabetes mellitus (disease which affects how the body uses sugar resulting in elevated blood sugar levels). During a review of Resident 2's "Order Summary Report, (OSR) dated 9/10/22, the OSR indicated, Resident 2, a 75-year-old male, was admitted on 7/13/22, with diagnoses of atherosclerotic heart disease (buildup of fatty deposits in the blood vessel walls), diabetes mellitus, hypertension (high blood pressure), and heart failure. During a review of Resident 3's AR, dated 9/11/22, the AR indicated, Resident 3, a 73-year-old male, was admitted to the facility on 12/28/21, with diagnoses of hypertension, peripheral vascular disease (narrowing, blockage, or spasms of blood vessels), and atherosclerosis (buildup of fatty deposits) of the arteries in the left leg, with amputation of two or more toes. During a review of Resident 4's AR, dated 9/11/22, the AR indicated, Resident 4, a 97-year-old male, was admitted to the facility on 1/13/15, with diagnoses of hypertension, heart failure, and atherosclerotic heart disease of the coronary artery (blood vessel in the heart). During a review of Resident 5's AR, dated 11/11/22, and OSR, dated 12/2/20, the AR indicated, Resident 5, a 77-year-old female, was admitted to the facility on 5/6/17. The OSR indicated, Resident 5 had diagnoses of chronic obstructive pulmonary disease (COPD- chronic inflammatory lung disease), heart failure, peripheral vascular disease, and kidney failure. During a review of Resident 6's OSR, dated 9/11/22, the OSR indicated, Resident 6, an 88-year-old female, was admitted on 3/24/22, with diagnoses of COPD, hypertension, heart failure, atrial flutter (the hearts upper chambers beat too quickly), and cardiomegaly (abnormal enlargement of the heart). During a review of Resident 7's OSR, dated 9/11/22, the OSR indicated, Resident 7, was admitted to the facility on 12/18/20, with diagnoses of Alzheimer's Disease (progressive mental deterioration) and hypertension. During a review of Resident 8's AR, dated 9/11/22, the AR indicated, Resident 8, a 77-year-old male, was admitted to the facility on 6/13/22, with diagnoses of hypertension, atrial fibrillation (an irregular and rapid heart rhythm that can lead to blood clots in the heart), and kidney failure. During a review of Resident 9's OSR, dated 9/11/22, the OSR indicated, Resident 9, 75-year-old female, was admitted to the facility on 11/29/21, with diagnoses of Alzheimer's Disease and low blood pressure. During a review of Resident 10's AR, dated 9/11/22, the AR indicated, Resident 10, a 55-year-old female, was admitted to the facility on 4/10/17, with diagnoses of diabetes mellitus and hypertension. During a review of Resident 11's AR, dated 9/10/22, the AR indicated, Resident 11, an 88-year-old female, was admitted on 3/29/19, with diagnoses of atherosclerotic heart disease, COPD, and heart failure. During a concurrent observation and interview on 8/9/22, at 9:59 AM, with Licensed Vocational Nurse (LVN) 1, in Nursing Station Two's hallway, LVN 1 was observed giving medications and did not take the residents' blood pressure, LVN 1 was observed looking up at the ceiling while writing blood pressure values for her assigned residents (Resident 1, Resident 12, Resident 13, Resident 14, and Resident 15) on a piece of paper. LVN 1 stated she took her residents' vital signs (BP, pulse, respiratory rate, temperature) at around 7:30 AM, but did not record them in PCC (Point-Click-Care- computerized nursing documentation). LVN 1 stated, "I wrote it on my gloves and throw [sic] my gloves away, but I remember all their blood pressures." During a concurrent observation and interview on 8/9/22, at 10:49 AM, in Nursing Station Two, LVN 1 was observed recording a longer list of residents' vital signs into the PCC log in. LVN 1 stated, the Certified Nursing Assistant (CNA) gave the list to her. LVN 1 stated, if she does not have time, the CNA will take blood pressures for her residents. During an interview on 8/9/22, at 4:58 PM, with Director of Nursing (DON), DON stated for residents taking BP medication, the LVNs should check the residents' BP just prior to giving their medication. DON stated the CNAs also check the residents' BPs at the beginning of their shift. During an interview on 8/10/22, at 8:57 AM, with Clinical Specialist (CS), CS stated, "The expectation is for the licensed nurse to take the vital signs if there are parameters [limits set by the physician for giving or holding a medication]. The expectation is that the licensed nurse retakes the blood pressure just prior to administering the medication. They can take the blood pressure when they arrive but would need to retake the blood pressure just prior to giving the medication." During a concurrent interview and record review, on 8/13/22, at 10:50 AM, with LVN 1, Resident 1's, Resident 2's, Resident 3's, Resident 4's, Resident 5's, Resident 6's, Resident 8's, Resident 9's, Resident 10's, and Resident 11's Medication Administration Records (MARs - report which serves as the legal record of the drugs administered to a patient by the nurse), dated 5/22 through 7/22 were reviewed. The MARs indicated, LVN 1's initials when she documented in PCC were "17J1." The following was reviewed with LVN 1: a. Resident 1's MAR indicated, "Check Blood Sugar BID [twice a day]. Call MD if blood sugar less than 70 and above 400 two times a day." It was noted the documentation of Resident 1's blood sugar in the MAR by LVN 1 were the same as the blood sugar documented in the MAR by LVN 6. The blood sugar of Resident 1 on 6/28/22 was documented in the MAR by the following LVN's: 6/28/22- 6:30 AM- BS 114- LVN 6 6/28/22- 4:30 PM- BS 114- LVN 1 b. Resident 2's MAR indicated, "1. Isosorbide Mononitrate [medication used to treat heart disease] ER Tablet Extended Release 24 Hour 30 MG (milligrams) Give 1 tablet by mouth one time a day . . . Hold if SBP (systolic blood pressure) lower than 110. 2. Losartan Potassium (medication used to treat high blood pressure) Tablet 50 MG Give 50 mg by mouth in the evening . . . Hold if SBP is less than 110. 3. Coreg (used to treat high blood pressure) Tablet 3.125 MG . . . Give 1 tablet by mouth two times a day. . . Hold for SBP < (less than) 110 or HR (heart rate) < 60." It was noted the documentation of Resident 2's blood pressure in the MAR by LVN 1 were the same as the blood pressure documented in the MAR by LVN 7. The blood pressure of Resident 13 from 7/3/22 to 7/19/22 were documented in the MAR by the following LVN's: 7/3/22- 9 AM- BP 128/76- LVN 7 7/3/22- 5 PM- BP 128/76- LVN 1 7/4/22- 9 AM- BP 128/76- LVN 1 7/4/22- 5 PM- BP 128/76- LVN 1 7/18/22- 9 AM- BP 128/80- LVN 1 7/18/22- 5 PM- BP 128/80- LVN 1 7/19/22- 5 PM- BP 128/80- LVN 1 Resident 2's MAR indicated, "Glipizide (used to treat high blood sugar) Tablet 10 MG. Give 10 mg by mouth two times a day." It was noted the documentation of Resident 2's blood sugar in the MAR by LVN 1 were the same as the blood sugars documented in the MAR by the following LVNs: 6/4/22 - 6:30 AM- BS 157- LVN 5 6/4/22- 4:30 PM- BS 157- LVN 1 6/13/22- 4:30 PM- BS 94- LVN 1 6/14/22- 4:30 PM- BS 94- LVN 1 6/18/22- 6:30 AM- BS 124- LVN 5 6/18/22- 4:30 PM- BS 124- LVN 1 6/19/22- 6:30 AM- BS 112- LVN 5 6/19/22- 4:30 PM- BS 112- LVN 1 6/26/22- 6:30 AM- BS 130- LVN 5 6/26/22- 4:30 PM- BS 130- LVN 1 6/27/22- 6:30 AM- BS 130- LVN 2 6/27/22- 4:30 PM- BS 130- LVN 1 6/28/22- 6:30 AM- BS 130- LVN 2 c. Resident 3's MAR indicated, 1. Hydrochlorothiazide Tablet (used to treat high blood pressure) 60 MG Give 0.5 tablet by mouth one time a day . . . Hold if SBP is less than 110, HR heart rate < less than 60." 2. Carvedilol (used to treat high blood pressure) Tablet 3.125 MG Give 1 tablet by mouth two times a day . . . hold if SBP less than 110, HR < 60." It was noted the documentation in the MAR by LVN 1 were the same as the blood pressure documentation in the MAR by LVN 7. The blood pressure of Resident 3 from 6/1/22 to 6/30/22 were documented in the MAR by the following LVN's" 6/11/22- 5 PM- BP 126/75- LVN 7 6/12/22- 9 AM- BP 126/75- LVN 1 6/12/22- 5 PM- BP 126/75- LVN 1. d. Resident 4's MAR indicated, "1. Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day . . . Hold for SBP < 110." 2. Losartan Potassium Tablet 25 MG Give 1 tablet by mouth one time a day . . . Hold if SBP less than 110." It was noted the documentation of Resident 4's blood pressure in the MAR by LVN 1 were the same as the blood pressure documented in the MAR by LVN 8, LVN 23, and LVN 9. The blood pressure of Resident 4 from 5/2/22 to 6/28/22 were documented in the MAR by the following LVN's: 5/2/22- 9 AM- BP 135/81- LVN 8 5/3/22- 9 AM- BP 135/81- LVN 1 5/3/22- 5 PM- BP 122/71- LVN 23 5/4/22-9 AM- BP 122/71- LVN 1 5/4/22- 5 PM- BP 128/83- LVN 23 5/5/22- 9 AM- BP 128/83- LVN 1 5/7/22- 5 PM- BP 126/70- LVN 9 5/8/22- 9 AM- BP 126/70- LVN 1 5/8/22- 5 PM- BP 126/70- LVN 1 5/9/22- 9 AM- BP 126/70- LVN 1 5/9/22- 5 PM- BP 126/70- LVN 1 5/10/22- 5 PM- BP 132/66- LVN 6 5/11/22- 9 AM- BP 132/66- LVN 1 5/17/22- 5 PM- BP 122/68- LVN 1 5/18/22- 9 AM- BP 122/68- LVN 1 5/19/22- 9 AM- BP 112/66- LVN 1 5/20/22- 9 AM- BP 112/66- LVN 1 6/3/22- 9 AM- BP 120/64- LVN 1 6/2/22- 5 PM- BP 120/64- LVN 10 6/3/22- 9 AM- BP 120/64- LVN 1 6/3/22- 5 PM- BP 107/55- LVN 9 6/4/22- 9 AM- BP 107/55- LVN 1 6/4/22- 5 PM- BP 107/55- LVN 1 6/5/22- 9 AM- BP 107/55- LVN 1 6/10/22- 5 PM- BP 139/89- LVN 25 6/11/22- 9 AM- BP 139/89- LVN 1 6/12/22- 5 PM- BP 124/66- LVN 11 6/13/22- 9 AM- BP 124/66- LVN 1 6/13/22- 5 PM- BP 124/66- LVN 1 6/14/22- 9 AM- BP 124/66- LVN 1 6/14/22- 5 PM- BP 124/66- LVN 1 6/15/22- 9 AM- BP 124/66- LVN 1 6/26/22- 9 AM- BP 112/66- LVN 4 6/26/22- 5 PM- BP 112/66- LVN 1 6/27/22- 9 AM- BP 112/66- LVN 1 6/27/22- 5 PM- BP 112/66- LVN 1 6/28/22- 9 AM- BP 112/66- LVN 1 e. Resident 5's MAR indicated, "Losartan Potassium . . . 25 MG Tablet Give two tablets by mouth two times a day . . . Hold if SBP less than 110, HR less than 60." It was noted the documentation of Resident 5's blood pressure in the MAR by LVN 1 were the same as the blood pressure documented in the MAR on the following dates: 6/2/22- 5 PM- BP 141/73- LVN 1 6/3/22- 9 AM- BP 141/73- LVN 1 6/8/22- 9 AM- BP 132/68- LVN 1 6/8/22- 5 PM- BP 132/68- LVN 1 6/9/22- 9 AM- BP 132/68- LVN 1 6/9/22- 5 PM- BP 132/68- LVN 1 6/11/22- 9 AM- BP 126/74- LVN 1 6/11/22- 5 PM- BP 126/74- LVN 1 6/12/22- 9 AM- BP 126/74- LVN 1 f. Resident 6's MAR indicated, "1. Amiodarone HCl (medication used to treat abnormal heart rhythm) Tablet 200 MG Give 1 tabled by mouth one time a day . . . hold if HR less than 60. 2. Lisinopril (medication used to treat high BP and heart failure) 5 MG Give 5 mg by mouth one time a day . . . Hold for SBP < 110 or HR < 60. 3. Metoprolol Tartrate (medication used to treat high BP) Give 12.5 mg by mouth three times a day . . . Hold for SBP less than 110 and HR less than 60." It was noted the documentation of Resident 6's blood pressure in the MAR by LVN 1 were the same as the blood pressure documented in the MAR by LVN 4. The blood pressure of Resident 6 from 6/12/22 to 6/28/22 were documented in the MAR by the following LVN's: 6/12/22- 9 AM- BP 118/68- LVN 1 6/12/22- 5 PM- BP 118/68- LVN 1 6/28/22- 9 AM- BP 110/52- LVN 4 6/28/22- 5 PM- BP 110/52- LVN 1 g. Resident 8's MAR indicated, "1. Metoprolol Tartrate (medication used to treat high BP) Tablet 50 MG Give 1 tablet by mouth two times a day . . . Hold for SBP less than 110. 2. Cozaar (medication used to treat high BP) Tablet 50 MG Give 1 tablet by mouth two times a day . . . Hold if SBP less than 110. 3. Nifedipine (medication used to treat high BP) ER Tablet Extended Release 24 Hour 60 MG Give 1 tablet by mouth in the evening . . . hold if SBP < 110." It was noted the documentation of Resident 8's blood pressure in the MAR by LVN 1 were the same as the blood pressure documented in the MAR by LVN 11 and LVN 12. The blood pressure of Resident 8 from 6/3/22 to 7/4/22 were documented in the MAR by the following LVN's: 7/3/22- 9 AM- BP 138/60- LVN 11 7/3/22- 5 PM- BP 138/60- LVN 1 7/4/22- 9 AM- BP 138/60- LVN 1 7/4/22- 5 PM- BP 138/60- LVN 1 7/8/22- 5 PM- BP 136/78- LVN 12 7/9/22- 9 AM- BP 136/78- LVN 1 7/18/22- 9 AM- BP 144/86- LVN 1 7/18/22- 5 PM- BP 144/86- LVN 1 7/19/22- 9 AM- BP 159/74- LVN 1 7/19/22- 5 PM- BP 159/74- LVN 1 7/31/22- 9 AM- BP 138/77- LVN 1 7/31/22- 5 PM- BP 138/77- LVN 1 7/3/22- 9 AM- BP 138/60- LVN 12 7/3/22- 5 PM- BP 138/60- LVN 1 7/4/22- 9 AM- BP 138/60- LVN 1 7/4/22- 5 PM - BP 138/60- LVN 1 h. Resident 9's MAR indicated, "Midodrine HCL (medication used to treat low BP) 5 MG Give 1 tablet three times a day . . . hold if SBP more than 140." It was noted the documentation of Resident 9's blood pressure in the MAR by LVN 1 were the same as the blood pressure documented in the MAR by LVN 7. The blood pressure of Resident 9 from 6/11/22 to 6/12/22 were documented in the MAR by the following LVN's: 6/11/22- 5 PM- BP 109/61- LVN 7 6/12/22- 9 AM- BP 109/61- LVN 1 6/12/22- 1 PM- BP 109/61- LVN 1 6/12/22- 5 PM- BP 109/61- LVN 1 i. Resident 10's MAR indicated, "1. Hydralazine HCl (medication used to treat high BP) Tablet 100 MG Give 1 tablet by mouth three times a day . . . Hold if SBP less than 110 and DBP less than 60. 2. Coreg (medication used to treat high BP) Tablet 25 MG . . . Give 1 tablet two times a day . . . HOLD IF SBP LESS THAN 110 and/or HR < 60. 3. Lisinopril (medication used to treat high BP and heart failure) Tablet 40 MG Give 40 mg by mouth one time a day . . Hold if SBP less than 110 and DBP less than 60. 4. Norvasc Tablet (medication used to treat high BP) 10 MG Give 1 tablet by mouth one time a day . . . Hold if SBP less than 110 and DBP less than 60. 5. Monitor BP every shift for hypertension. Give prn (as needed) Clonidine (medication used to treat high BP) as indicated." It was noted the documentation of Resident 10's blood pressure in the MAR by LVN 1 were the same