Health inspection·October 18, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to accurately complete a medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route) on post- discharge medications for one of three residents (Resident 1) when Resident 1 was discharged home with a discontinued (no longer provided) medication. This failure had the potential for Resident 1 to take an unprescribed medication in error which could negatively affect his health and well-being. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in 2024 with diagnoses that included depression (a mental health condition that involves a persistent feeling of sadness and loss of interest that interferes with daily life) and muscle weakness. A review of Resident 1's Order Summary Report, (list of physician orders) dated 6/27/24, indicated Resident 1 was prescribed Mirtazapine (medication to treat depression) 7.5 mg (milligram- a unit of measure) one tablet at bedtime. Further review of the record indicated the order for Mirtazapine was discontinued on 6/28/24. A review of Resident 1's Medication Administration Record, (MAR) indicated Resident 1 received Mirtazapine on 6/27/24. A review of Resident 1's Discharge Instructions, with an effective date of , .Date of discharge: [DATE] .Final Discharge Location: Home/Family Assist .7/31/24, indicated Medications .Please see attached medication instruction form . A review of Resident 1's Transfer/ Discharge Report, dated 7/31/24, indicated Mirtazapine was not found on the list of Resident 1's current medications. A review of Resident 1's Discharge Meds Release ., (list of medications sent home when the patient is discharged ) dated 8/1/24, indicated Mirtazapine was 1 of 12 medications sent home with Resident 1. During a concurrent interview and record review on 10/18/24, at 10:45 a.m., with the Director of Nursing (DON) and Licensed Nurse (LN) 1, Resident 1's discharge records were reviewed. LN 1 confirmed the nurse that discharged Resident 1 gave Mirtazapine, a discontinued medication to Family Member Page 1 of 2 555186 555186 10/18/2024 Lincoln Square Post Acute Care 1032 N. Lincoln Street Stockton, CA 95203

F 0661 Level of Harm - Minimal harm or potential for actual harm (FM) 1 to take home that was not on the list of medications in Resident 1's discharge instructions. LN 1 stated that when the error was discovered by facility administration, the nurse was counseled and no longer worked at the facility. LN 1 further stated FM 1 should not have been given a medication that was not listed on Resident 1's current discharge medication list. The DON and LN 1 both confirmed there was a risk to Resident 1 when a discontinued medication was sent home with the resident and FM 1. Residents Affected - Few During a phone interview on 10/18/24, at 11:29 a.m., with FM 1, FM 1 confirmed Mirtazapine was one of the medications that was sent home with Resident 1 when he was discharged from the facility. FM 1 stated she did not give Mirtazapine to Resident 1 as it was not listed on his discharge instructions list of medications. During a review of a facility policy and procedure (P&P) titled, Discharge Medications, dated December 2016, indicated, .2. The Charge Nurse shall verify that the medications are labeled consistent with current physician orders including instructions for use .4. The nurse will reconcile pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented. 5. The nurse shall review medication instructions with the resident, family member or representative before the resident leaves the facility . During a review of a facility P&P titled, Discharge Summary and Plan, dated December 2016, indicated, .When a resident's discharge is anticipated, a discharge summary and a post-discharge plan will be developed to assist the resident to adjust to his/her new living environment .2. The discharge summary will include .Medication Therapy (all prescription and over-the-counter medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident) .As part of the discharge summary, the nurse will reconcile all pre-discharge medications with the resident's post-discharge medications. The medication reconciliation will be documented . 555186 Page 2 of 2