Health inspection·July 18, 2023

F 0675 Honor each resident's preferences, choices, values and beliefs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide care and services to attain and maintain highest practicable physical and mental well-being when a medication to aid sleep was not clarified and administered as ordered by the physician. Residents Affected - Few This failure had resulted in the lack of restful sleep leading to negative behaviors like yelling and screaming. Findings: Review of Resident 1's admission Record indicated Resident 1 had been known to the facility since April 2022, with diagnoses that included depression (persistent feeling of severe sadness with symptoms that include not being able to sleep, feeling hopeless, irritable or anxious), psychosis (severe mental disorder causing abnormal thinking and perception) and dementia (loss of mental functions affecting daily life and activities). [Reference:https://medical-dictionary.com/]. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/24/23, the MDS, under Section D- Mood, indicated Resident 1 had trouble falling asleep, or sleeping too much and had been feeling tired or having little energy for seven to 11 days over a two-week period. During a concurrent interview and review of Resident 1's care plans with Licensed Vocational Nurse (LVN) 1 on 4/11/23 at 12:25 p.m., LVN 1 stated a care plan addressing Resident 1's trouble falling asleep should have been completed but was not. LVN 1 stated Resident 1 was on Melatonin (supplement that helps establish normal sleep pattern) for sleep aid but there was no care plan to address Melatonin use to evaluate its effectiveness as a sleep aid. [Reference:https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f8a2e032-7457-434e-bfea-84178bf1f544]. During a review of Resident 1's Order Summary Report Active Orders as of 3/1/23, the report indicated an order dated 10/27/22 to give Melatonin 3 milligram tablet :Give 2 tablets by mouth as needed for dietary supplement [to] improve circadian rhythm (physical, mental and behavioral changes that follow a 24-hour cycle). However, the order did not indicate the frequency and the time of administration. During a concurrent interview and review of Resident 1's Medication Administration Record (MAR) for March 2023 with Director of Nursing (DON), on 4/11/23 at 11:32 a.m., DON stated Melatonin should have been administered to Resident 1 on 3/28/23 to help with sleep. DON stated the MAR indicated Resident 1 was not given Melatonin. DON also stated, although Resident 1 had difficulty falling asleep Page 1 of 2 555287 555287 07/18/2023 Diamond Ridge Healthcare Center 2351 Loveridge Road Pittsburg, CA 94565

F 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and was on Melatonin as needed, the clinical record did not indicate there was monitoring to evaluate the need and effectiveness of Melatonin. During a telephone interview with Interim Director of Nursing (IDON), on 6/5/23 at 1:52 p.m., IDON stated the physician's order for Melatonin, did not specify the time of administration. IDON further stated, the attending physician should still be notified to seek clarification. During an interview with Resident 1 on 4/11/23 at 12:40 p.m., Resident 1 stated having had trouble falling asleep and did not know a medication promoting sleep could be requested as needed. During an interview with LVN 2 on 4/11/23 at 12:50 p.m., LVN 2 works the morning shift and stated having observed Resident 1 asleep past 9 a.m. LVN 2 further stated Resident 1 had complained of feeling tired in the morning. During a telephone interview with LVN 3 (night shift nurse), on 6/5/23 at 10:34 a.m., LVN 3 stated, on 3/28/23, Resident 1 yelled/screamed, and asked to be pulled up in bed, then asked to sit up at the edge of the bed, and asked for a cheese sandwich, yelling and screaming in between these requests. LVN 3 stated Resident 1 had been unable to fall asleep during the night shift but was not given Melatonin because it was already past midnight, LVN 3 stated it was Against state law to administer a sleep medication past midnight. During a telephone interview with LVN 4 on 6/5/23 at 11:22 a.m., LVN 4 stated, Resident 1's constant yelling and screaming could be heard from the other station during the night shift. LVN 4 stated if there was a written order for Melatonin, the afternoon shift charge nurse should administer the medication, not the night shift. LVN 4 also stated, if the medication was not given in the evening before night shift started, and the resident still needed it, the attending physician should be notified to write another order for that medication to be given by the night shift nurse. During a concurrent interview and record review with IDON on 7/18/23 at 10:45 a.m., IDON stated, the expectation was for the licensed nurse to clarify the medication order with the physician. IDON further stated the attending physician needed to know of Resident 1's abnormal sleep pattern so that the medication regimen could be changed. IDON stated the medical record did not indicate that such notification to the attending physician was made. During a telephone interview with Consultant Pharmacist (CP) on 7/18/23 at 11:06 a.m., CP stated the medication could still be therapeutic and will help promote sleep even if administered after 11 p.m. 555287 Page 2 of 2