Health inspection·May 1, 2025

Idylwood Care Center Recertification Survey (TTG411) Exit Date - 4/11/25 The following reflects the findings of the California Department of Public Health during a recertification survey Event # TTG411 Representing the Department, HFEN # 50855 State Citation B was written REGULATORY VIOLATION(S): F759 §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(1) Medication error rates are not 5 percent or greater. On 4/07/2025, an unannounced visit was conducted at the facility for a recertification survey. The facility had a medication error rate of 18.75% when six medication errors occurred out of 32 opportunities during the medication administration for three out of seven residents (Resident 3, Resident 34, and Resident 139). The failures resulted in the nursing staff not following physician's orders and the facility's policy and procedures (P&P) and had the potential for medication complications or residents not receiving full therapeutic effects of the medication. Findings: 1. During the medication administration observation on 4/7/24 at 4:35 p.m., Licensed Vocational Nurse F (LVN F) was observed administering five medications for Resident 3. Included in the medications was eye drops, Brimonidine Tartrate [used to lower pressure in the eyes in patients with glaucoma (high pressure in the eyes that may damage nerves and cause vision loss)]. LVN F asked Resident 3 to open the eyes but did not instruct the resident to look up. LVN F instilled one drop of the medication directly to the inner corner of Resident 3's eye without pulling the lower eyelid down. As soon as the eye drop was instilled to inner corner of Resident 3's eyes, LVN J immediately wiped Resident 3's eyes with a tissue. LVN J did not apply gentle pressure on Resident 3's tear duct after administering the eye drops. During an interview after the medication administration, on 4/7/25 at 4:53 p.m. with LVN F, he confirmed he instilled the drops directly into the inner corner of Resident 3's eyes and did not pull the resident's lower eyelid to make a pocket to instill the medication in during eye drop administration. He further stated he normally administered the eye drop in the center of the eye or pupil [circular black opening in the center of the iris (the colored part of the eye that surrounds the pupil) of the eye]. During a review of Resident 3's physician's order indicated an order, dated 2/26/25 for Brimonidine Tartrate Instill 1 drop in both eyes three times a day for Glaucoma. During an interview on 4/8/25 at 3:13 p.m., with the Director of Nursing (DON), she stated during eye drop administration, the nurses should make a pocket and instill the eye drop in the conjunctival sac (the pocket where eye drops and ointments are typically administered). During phone interview on 4/10/25 at 3:39 p.m., with the Facility Pharmacist Consultant (FPC), the FPC stated for eye drop administration the nurse should wash hands, wear gloves, instruct the patient to look up if the patient cannot follow instruction, they must hold the eyelid (lower). According to MedlinePlus.gov, a service of the National Library of Medicine (NLM), the world's largest medical library, which is part of the National Institutes of Health (NIH). Indicated the following for Brimonidine Ophthalmic: "To instill eye drops, follow these steps: ... 5. While tilting your head back, pull down the lower lid of your eye with your index finger to form a pocket ... 7. While looking up, gently squeeze the dropper so that a single drop falls into the pocket made by the lower eyelid. Remove your index finger from the lower eyelid ... 9. Place a finger on the tear duct and apply gentle pressure [prevent the medication from draining into the nose and reduces the risk of systemic side effects]. 10. Wipe any excess liquid from your face with a tissue ..." During a review of the facility's P&P titled "6.0 General Dose Preparation and Medication Administration "Revised date 1/1/13, indicated, "Applicability: This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications ... 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: ...Provide the resident with any necessary instructions. 5.8 Follow manufacturer medication administration guidelines ..." 2. During the medication administration observation on 4/8/25 at 8:36 a.m., Registered Nurse E (RN E), was observed preparing five medications, one liquid medication, four tablets of three different medications, and one powdered medication for Resident 34. The four tablets were one tablet of aspirin (treat mild to moderate pain) 81 milligrams (mg, unit of measurement); two tablets of carbamazepine (used to treat seizures, nerve pain) 200 mg; and one tablet of lithium (treat bipolar disorder, a mental condition in which a person has wide or extreme swings in their mood) 300 mg. The resident was receiving medications via gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). RN E placed the four tablets of three different medications in one small medication cup, then she put it inside the pill crusher pouch and crushed all the three medications together. She put the three crushed medications in one cup of 4 ounces (oz, unit of measurement) of water, which was mixed with 17 grams of polyethylene glycol powder (treat occasional constipation). On 4/8/25 at 8:45 a.m., RN E was observed administering the medication to Resident 34 via G-tube. RN E flushed the G-tube with water, and she administered the four mixed medications in one cup using a 60 ml (milliliter, unit of measurement) syringe (commonly used in a wide range of applications, including medication delivery, fluid injections, blood draws, and laboratory testing), then she flushed the G-tube with water. During an interview shortly after the observation, on 4/8/25 at 8:59 a.m., RN E confirmed she crushed the three medications all together and mixed it with 17 gram of polyethylene powder in the cup, total of four mixed medications was administered to Resident 34's G-tube together. The liquid medication was administered separately. RN E stated the three medications should be crushed separately. She stated she should have flushed 15 ml in between each mediation. RN E also stated the four medications should be administered separately. She further stated the medications has different interactions. During an interview on 4/8/25 3:15 p.m., with the DON, she stated during G-tube medication administration, nurses should crush the medication separately and administer the medications separately with flushing in between. During a review of Resident 34's physician's order indicated an order, dated 1/25/24 "Enteral Feed (also known as tube feeding) Order every shift flush tube with 15 ml of water in between each medication." During a telephone interview on 4/10/25 at 3:37 p.m., with the Facility Pharmacist Consultant (FPC), the FPC stated for G-tube medication administration, the nurse should administer the medication in separate cups and flush after each medication. She further stated it is a precaution because some drugs might have an interaction. During a review of the facility's P&P titled, "ENTERAL THERAPY (Tube Management, Feeding, Medications) "Revised date 9/1/13, indicated,"... III MEDICATION AND ADMINISTRATION VIA ENTERAL TUBE A. Procedure for Administering Medication: ... 4. Administer each medication one at a time, with water flushes prior to administration, due to risk for physical and chemical incompatibilities, potential for tube obstruction, and potential for altered therapeutic drug response ..." 3. During the medication administration observation on 4/8/25 at 9:04 a.m., Registered Nurse I (RN I), was observed preparing five medications for Resident 139. Included in the medications was tamsulosin (used in men to treat the symptoms of an enlarged prostate [prostate is a gland in the male reproductive system]) 0.4 mg 2 capsules. The medication was not in the cart, and RN I stated she will check the medication room for tamsulosin. RN I came back without the tamsulosin, and she stated the medication is not available. She further stated she will call the pharmacy. During an interview on 4/8/25 at 1:18 p.m., when RN I was asked whether she was able to give tamsulosin to Resident 139, RN stated it was not given and the pharmacy will deliver the medication later in afternoon. During a review of Resident 139's physician's order indicated an order for Tamsulosin capsule 0.4 mg give 2 capsules by mouth one time a day for BPH (benign prostatic hyperplasia, condition when the prostate gland is larger than normal), dated 5/29/24. During a review of Resident 139's Medication Administration Record (MAR) indicated the 4/8/25 9 a.m. administration for tamsulosin 0.4 mg give 2 capsule was marked "18" meaning "medication not available." During an interview of 4/9/25 at 3:36 p.m., with the DON, she stated medication should have been ordered on time and stated medications should be available. She further stated Resident 139 did not receive the medication tamsulosin yesterday. During a review of the facility's P&P titled, "MED PASS, MEDICATION ADMINISTRATION ESSENTIALS "Revised date 9/1/13, indicated," ... 2. The licensed nurse administers medications within one hour before or one hour after the scheduled administration time. ... E. Medication Rights Licensed nurses are to follow the seven "rights "of medication: 4. The right time." This violation had a direct or immediate relationship to the health, safety, or security of the residents