Health inspection·March 11, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure physician's orders were implemented for one of five sampled residents (Resident 1) when an order for a topical (used on the skin) cream used for pain was not entered from the hospital orders into Resident 1's medication orders. Residents Affected - Few This failure resulted in Resident 1 not having access to her topical pain cream. Findings: Resident 1 was admitted to the facility late 2023 with diagnoses which included respiratory failure and muscle weakness. During a review of Resident 1's AFTER HOSPITAL CARE, dated 12/13/23, the document indicated, Medication List .MISCELLANEOUS CREAMS TOPI (sic) Apply to the affected area if needed [arthritis pain]. Indications: arthritis pain [brand name of cream, over the counter used for pain]. During a review of Resident 1's Order Summary Report [OSR], dated 12/13/23, the OSR does not have (brand name of cream) listed as an order. During a review of Resident 1's Progress Notes [PN], Type: NURSE PROGRESS NOTE, dated 12/17/23 at 6:02 a.m. the PN indicated, Resident c/o [complains of] pain to neck and back with little relief from Tylenol. Resident requesting [something stronger] as stating she did not sleep due to pain . During a review of Resident 1's PN, dated 12/20/23 at 12:20 p.m., the PN indicated, Resident complains of pain throughout the shift .resident does complain of pain before the next dose is able to be administered . During a review of Resident 1's PN, Type: PHYSICIAN PROGRESS NOTE, dated 12/20/23 at 4:14 p.m. the PN indicated, .patient noting back and neck pain . During an interview on 3/11/24 at 12:44 p.m. with Registered Nurse (RN) 1, RN 1 was asked the process for new admission medication orders and stated, All hospital orders go on the MAR [Medication Administration Record] .any medication that the doctor orders go onto the MAR. During an interview on 3/11/24 at 2 p.m. with the Director of Nursing (DON), the chart for Resident 1 was reviewed, the DON was asked if (brand name of cream) was considered a physician order and the DON stated, Yes, they are all physician orders, especially for pain. During a concurrent interview and record review on 3/11/24 with the DON at 2:19 p.m. the physician Page 1 of 2 555180 555180 03/11/2024 Gold Country Health Center 4301 Golden Center Drive Placerville, CA 95667

F 0684 Level of Harm - Minimal harm or potential for actual harm orders for Resident 1 were reviewed. The DON confirmed the order for (brand name of cream) was not on the MAR, Treatment Administration Record (TAR) or on the physician orders. The DON stated the order for the cream was not entered because the directions from the hospital were unclear, and the order should have been clarified with the physician. The DON confirmed there was no documentation the order was clarified and stated, There should have been some documentation . Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders, dated 7/16, the P&P indicated, .Drug and biological orders must be recorded on the physician's order sheet in the resident's chart . 555180 Page 2 of 2