Health inspection·March 28, 2023

REGULATION VIOLATION: Title 22 72523(a) 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. Title 22 72311(a)(1)(A) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. On January 23, 2023, at 2:00 PM, an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care and treatment concerns related to Patient A’s medication not being transcribed electronically when the system removed the Keppra (a medication used to prevent seizures) order due to an automatic stop date. This error was not identified by the staff assigned to do the recapitulation (a review of all written and verbal orders since the prior month), resulting in the Keppra not being renewed and administered for Patient A from December 3, 2022, at 9:00 AM (scheduled medication administration time) through December 10, 2022, at 4:00 PM (scheduled medication administration time). Patient A had a grand mal seizure (also known as a tonic-clonic seizure, characterized by intense muscle contractions and loss of consciousness) on December 11, 2022. The facility failed to follow its policies and procedures to ensure Patient A’s medication order was renewed, which resulted in the medication not being administered for eight days from December 3, 2022, 9:00 AM, through December 10, 2022, 4:00 PM. The facility also failed to provide continuing assessment of Patient A’s care needs when it failed to monitor and track her medication stop date and failed to identify and assess her continued need of the medication, contributing to Patient A sustaining a grand mal seizure on December 11, 2022. Patient A was a 52-year-old female, admitted to the facility on March 9, 2017, with diagnoses of hemiplegia (a condition caused by brain damage that leads to complete paralysis of half of the body) and hemiparesis (a weakness of one side of the body caused by brain damage) following other cerebrovascular disease (a loss of blood flow to part of the brain, which damages brain tissue), other epilepsy (group of disorders marked by problems in the normal functioning of the brain, causing seizures), and vascular dementia (refers to changes in memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A review of Patient A’s “5 Day MAR – Final” (MAR – medication administration record), dated from November 28, 2022, to December 2, 2022, indicated Patient A’s Keppra medication order was last administered on December 2, 2022, at 4:09 PM. The MAR dated from December 3, 2022, to December 7, 2022, indicated Patient A’s Keppra medication order was discontinued on December 3, 2022, at 7:54 AM. The MAR dated from December 8, 2022, to December 12, 2022, indicated, Patient A’s Keppra medication order was next administered on December 11, 2022, at 9:10 AM. Patient A’s MAR further indicated 16 consecutive Keppra medication administrations were not given to Patient A between December 3, 2022, to December 10, 2022. A review of Patient A’s MAR dated from November 28, 2022, to December 12, 2022, indicated, Patient A’s Keppra medication order was 1,000 mg (mg-milligrams, unit of measurement) to be given by mouth twice a day, with a start date of December 3, 2021, and a stop date of December 3, 2022. The MAR indicated medication order for Keppra was discontinued from the system on December 3, 2022, at 7:54 AM and the order was not renewed. A review of Patient A’s “Pharmacist Monthly Medication Review/Consultation,” dated December 2022, indicated Patient A had a seizure condition and Patient A’s indicated medication to treat the seizure condition was Keppra. The document indicated in the discussion notes with nursing, Patient A “had a seizure this month and appeared to be related to Patient A not receiving their Keppra”. A review of Patient A’s “Patient Nursing Progress Notes” dated December 11, 2022, at 5:52 AM, indicated Patient A had a witnessed grand mal seizure, lasting approximately one and a half minutes. The “Patient Nursing Progress Notes” indicated Patient A suddenly raised up left arm, became stiff and started shaking mildly and was unresponsive throughout the seizure and confused following the seizure. During a concurrent observation and interview on February 13, 2023, at 9:43 AM, in Patient A’s room, Patient A was observed lying in bed with a nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and wearing glasses. Patient A was observed to have her right hand contracted (drawn up) into a fist. Patient A was able to use her left hand and arm to grab her water tumbler and tablet. Patient A stated, “this one, this one, and this one is good, but that one is not.” Patient A was asked, who were this one and that one, and Patient A was unable to identify who they were. Patient A was unable to focus with the interview questions. During a telephone interview on February 13, 2023, at 2:20 PM, received by the surveyor from a family member (FM 1) of Patient A, FM1 stated Patient A’s seizure medication fell off the system (was not transcribed electronically) and Patient A was without seizure medication for eight to nine days and had a grand mal seizure. FM 1 stated, they were called about Patient A’s seizure and told that the facility would investigate the occurrence. A review of Patient A’s “Long Term Care Plan” (Care Plan- specific interventions to provide effective and person-centered care to meet the patient's needs), undated, indicated Patient A has a potential for alteration in health maintenance related to diagnosis of epilepsy/seizure problem. The “Long Term Care Plan” indicated Patient A “did not receive her Keppra as ordered due to a system error for renewal of medication” …. Patient A “had a seizure on December 11, 2022, no injuries noted as a result of the seizure, MD was notified and Keppra was reordered.” During an interview on February 14, 2023, at 8:20 AM, with the Minimum Data Set (MDS Nurse - a nurse who assesses residents and collaborates with other healthcare professionals to create resident specific care plans), the MDS Nurse stated Patient A was not given multiple scheduled Keppra medication doses during a COVID-19 (a highly contagious respiratory disease) outbreak in the facility. The MDS Nurse stated Patient A was noticed by the night nurse on December 11, 2022, at 5:52 AM, to be having a seizure and at that time it was noticed that Patient A had not been receiving her Keppra medication. The MDS Nurse stated the Keppra for Patient A had been removed by the electronic health record (EHR) system automatically, and the facility completed an investigation and notified family when Patient A had a seizure. During an interview on February 14, 2023, at 3:30 PM, with a Registered Nurse (RN1), RN 1 stated, the system in place to prevent missed medication was the monthly review with the pharmacist and RN 1. RN 1 stated, at the time of the occurrence, the EHR system would send a report to the printer at the nurses’ station notifying the nurses of medications that had a stop date that would soon occur. The printed page would then be placed on the nurses’ station desk where the medication nurse would determine the next action which may include faxing the pharmacy if a refill is needed. RN 1 stated they are unable to verify where the report indicating Patient A’s Keppra medication stop date had been placed. A review of Patient A’s “Order Chronology,” (physician orders) dated February 15, 2023, indicated, Patient A‘s physician order for “Keppra, oral tablet, 1,000 mg, one tablet taken by mouth twice a day” with a start date from December 11, 2022, at 8:33 AM. The physician orders indicated Keppra was the only seizure medication prescribed for Patient A. During a concurrent interview and record review on February 15, 2023, at 2:32 PM, with the Director of Nursing (DON), the DON stated Patient A was the only resident listed on the facility’s undated document titled, “Patients Receiving Seizure Medications,” in the facility. During an interview on February 15, 2023, at 3:47 PM, with the Pharmacist (RPH), the RPH stated, the monthly medication regimen review (an evaluation of the medication regimen of a resident) is completed by the RPH. The RPH stated the stop dates for medications were not looked at prior to Patient A’s medication error. The RPH stated order recapitulations (recaps - a report completed by the medical doctor with their decision to continue or discontinue an order) are forwarded to the medical doctor (MD 1). The RPH stated the recap process had stopped due to staff not completing the recap process at the time of Patient A’s medication error. The RPH stated had the stop date for Patient A’s Keppra been noted he would have referenced his concerns to the DON and/or the interdisciplinary team (a group of professional and direct care staff that have primary responsibility for the development of a plan for the care of a patient). During an interview on February 15, 2023, at 5:08 PM, with the DON, the DON stated they noticed on the day of Patient A’s seizure that the EHR system was automatically discontinuing medications based on the stop dates in the EHR system. The DON stated MD 1 was able to review the orders in the EHR system and choose whether to continue or discontinue any orders, including medication orders. The DON stated the report with all orders was printed and included all medications and the medication stop dates. The DON was asked if the stop date had been noticed prior to Patient A’s seizure, would Patient A’s seizure have been avoidable? The DON replied that Patient A had a history of refusing medications before and did not know if Patient A’s missed Keppra medication administrations had caused Patient A to sustain a grand mal seizure. A review of the facility’s policy and procedure (P&P) titled, "Physician's Orders – SNF” [Skilled Nursing Facility], undated, indicated "Procedure: 1.All SNF residents nursing and medication orders shall be renewed on a monthly basis… . 7.The following shift is to verify orders for completion and accuracy. 8. All skilled nursing charts will be checked for new orders every 24 hours during the night shift by a licensed staff member for accuracy and completion of orders…” During a concurrent interview and record review on February 16, 2023, at 10:47 AM, with the DON, the DON was asked if the facility’s P&P titled, “Physician’s Orders – SNF”, undated, was followed in reference to item 1, which indicated, "All SNF residents nursing and medication orders shall be renewed on a monthly basis." The DON stated this was a system error and was not completed for Patient A. Conclusion: The facility failed to follow its policies and procedures to ensure Patient A’s medication order was renewed, which resulted in the medication not being administered for eight days from December 3, 2022, 9:00 AM, through December 10, 2022, 4:00 PM. The facility also failed to provide continuing assessment of Patient A’s care needs when it failed to monitor and track her medication stop date and failed to identify and assess her continued need of the medication, contributing to Patient A sustaining a grand mal seizure on December 11, 2022. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.