Health inspection·January 2, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services according to professional standards of quality for four of seven sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4), when doses of antibiotics (medicine that fights bacterial infection) were missed and/or not administered intravenously (IV; into the vein) on time as indicated in physician's orders. Residents Affected - Some This failure increased the residents' potential to have unmet health needs. Findings: 1. A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute cystitis (bladder infection) and urinary tract infection (UTI). A review of a record titled, IV Administration, dated 12/23, indicated one gram (a unit of measure) of ertapenem (an antibiotic) to be administered to Resident 1 one time a day for UTI for five days. A review of Resident 1's Location of Administration Report, dated 1/3/24, indicated the 8 a.m. scheduled dose of ertapenem was administered on 12/30/23 and 12/31/23 at 9:21 a.m. and 9:13 a.m., consecutively. 2. A review of an admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including left ankle and foot osteomyelitis (bone infection) and left foot ulcer. A review of Resident 2's Minimum Data Set (MDS; an assessment tool), dated 11/17/23, indicated Brief Interview of Mental Status (BIMS) score was 12 of 15 with good memory. During an interview on 1/2/24 at 11:09 a.m. with Resident 2, Resident 2 stated staff missed doses of his antibiotic on Christmas evening and day. A review of a record titled, IV Administration, dated 12/23, indicated one gram of ceftriaxone (an antibiotic) to be administered to Resident 2 one time a day and 1500 milligrams (a unit of measure) of vancomycin (an antibiotic) to be administered to Resident 2 two times a day for left foot osteomyelitis. A review of Resident 2's Location of Administration Report, dated 1/3/24, indicated the following: · On 12/3/23, 12/8/23, 12/9/23, 12/13/23, 12/15/23, and 12/20/23, the 11 a.m. scheduled doses of ceftriaxone were administered at 3:11 p.m., 12:16 p.m., 3:45 p.m., 3:42 p.m., 1:28 p.m., and Page 1 of 3 555180 555180 01/02/2024 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0658 3:15 p.m. consecutively. Level of Harm - Minimal harm or potential for actual harm · On 12/28/23, the 12 p.m. scheduled dose of ceftriaxone was administered at 4:53 p.m. Residents Affected - Some · On 12/9/23, 12/20/23, 12/29/23, and 12/31/23, the 8 a.m. scheduled doses of vancomycin were administered at 3:43 p.m., 11:48 a.m., 9:27 a.m., and 9:25 a.m. consecutively. · On 12/3/23, the 9 a.m. scheduled dose of vancomycin was administered at 2:28 p.m. · On 12/13/23, the 2 p.m. scheduled dose of vancomycin was administered at 3:43 p.m. · On 12/23/23 and 12/24/23, the 8 p.m. doses of vancomycin were missed. 3. A review of an admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including right knee infection and long-term use of antibiotics. A review of Resident 3's MDS, dated [DATE], indicated BIMS score was 15 of 15 with good memory. During an interview on 1/2/24 at 11:32 a.m. with Resident 3, Resident 3 stated there had been times where there was delayed administration of his IV antibiotic. Resident 3 further stated on 12/20/23, staff missed two afternoon doses of his antibiotic and told him the IV person did not show up. A review of a record titled, IV Administration, dated 12/23, indicated two grams of ampicillin (an antibiotic) to be administered to Resident 3 every four hours for knee infection. A review of Resident 3's Location of Administration Report, dated 1/2/24, indicated the following: · On 12/14/23 and 12/20/23, the 6 a.m. doses of ampicillin were missed. · On 12/17/23, the 2 p.m. dose of ampicillin was missed. · On 12/24/23, the 12 a.m., 4 a.m., and 4 p.m. doses of ampicillin were missed. · On 12/30/23, the 4 a.m. dose of ampicillin was missed. · On 12/9/23, the 10 p.m. dose of ampicillin was administered at 12:15 a.m. · On 12/13/23, 12/15/23, and 12/20/23, the 10 a.m. doses of ampicillin were administered at 1:08 p.m., 1:23 p.m., and 3:17 p.m. consecutively. · On 12/13/23 and 12/20/23, the 2 p.m. doses of ampicillin were administered at 3:44 p.m. and 5:27 p.m. consecutively. · On 12/18/23, the 6 a.m. dose of ampicillin was administered at 7:22 a.m. · On 12/20/23, the 6 p.m. dose of ampicillin was administered at 7:36 p.m. · On 12/21/23 and 12/26/23, the 12 p.m. doses of ampicillin were administered at 3:25 p.m. and 3:41 p.m. consecutively. 555180 Page 2 of 3 555180 01/02/2024 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0658 · On 12/23/23, the 4 p.m. dose of ampicillin was administered at 8:19 p.m. Level of Harm - Minimal harm or potential for actual harm · On 12/24/23 and 12/30/23, the 8 p.m. doses of ampicillin were administered at 9:41 p.m. and 9:34 p.m. consecutively. Residents Affected - Some · On 12/25/23, the 12 a.m. and 4 a.m. doses of ampicillin were administered at 6:22 a.m. · On 12/27/23 and 12/29/23, the 8 a.m. doses of ampicillin were administered at 11:02 a.m. and 9:29 a.m. consecutively. 4. A review of an admission record indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including pneumonia (lung infection) due to coronavirus disease 2019 and was discharged to the acute care hospital on [DATE]. A review of a record titled, IV Administration, dated 12/23, indicated two grams of cefazolin (an antibiotic) to be administered to Resident 4 two times a day for pneumonia. A review of Resident's Location of Administration Report, dated 1/3/24, indicated on 12/20/23, the 8 a.m. scheduled dose of cefazolin was administered at 5:26 p.m. During an interview on 1/2/24 at 11:22 a.m. with Licensed Nurse 1 (LN 1), LN 1 stated there had been times where there was no registered nurse (RN) in the facility to administer the IV antibiotics and she struggled to find an RN to administer Resident 3's IV antibiotic which was scheduled every four hours. LN 1 further stated there had been delayed administration or missed doses of vancomycin for Resident 2 and ampicillin for Resident 3. During an interview on 1/2/24 at 1:32 p.m. with LN 2, LN 2 stated some residents missed doses of their antibiotics and one of them was Resident 3. During an interview on 1/2/24 at 3:04 p.m. with Administrator (ADM) and Assistant Director of Nursing (ADON), both ADM and ADON confirmed there were missed doses and/or delayed administration of IV antibiotics to Resident 1, Resident 2, Resident 3, and Resident 4. ADM and ADON stated nurses should have documented the time they administered the IV antibiotics and followed the physician's order and prescribed time frame. ADM and ADON further stated there might have been a potential for residents to have adverse events when nurses delayed or missed their IV antibiotics which reduced the time between the scheduled doses and its therapeutic effects. A review of the facility's policy titled, Medication Administration-General Guidelines, dated 3/18, indicated Medications are administered in accordance with written orders of the attending physician .within 60 minutes of scheduled time .The individual who administers the medication dose records the administration on the resident ' s MAR [Medication Administration Record] directly after the medication is given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 555180 Page 3 of 3