Health inspection·November 1, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to notify and consult with the physician when Resident 1 was unable to sleep despite the use of sleep medication. This failure potentially contributed to increase in episodes of negative behavior and falls and had the potential to result in delayed modification of treatment regimen. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (abnormal blood sugar levels), non-traumatic chronic subdural hemorrhage (brain injury), dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and epilepsy (a disorder of the brain characterized by repeated seizures). During an observation on 11/1/23 at 11:43 a.m., Resident 1 was in a wheelchair in front of the nurses' station with a blanket covering his shoulder and upper torso. Resident 1 appeared tired and engaged in a conversation with Certified Nursing Assistant (CNA) 1 in a monotone voice. During an interview on 11/1/23 at 12:10 p.m. with CNA 1, CNA 1 stated Resident 1 had a behavior of screaming and yelling at the staff, got irritated very quickly when he did not get what he wanted. CNA 1 stated Resident 1's agitation was usually triggered by pain and when delirious from lack of sleep. During a review of Resident 1's Order Summary Report, dated 11/2/23, the Order Summary Report indicated an order dated 4/14/23 for Resident 1 to receive Temazepam (a strong sedative) oral capsule 15 milligrams (mg) one capsule by mouth at bedtime for insomnia manifested by inability to sleep. The report also indicated an order dated 9/27/23 for melatonin (a hormone that regulates sleep-wake cycle) five mg two oral tablets by mouth in the evening to regulate circadian rhythm. During a review of Resident 1's Medication Administration Record (MAR) for September 2023, the MAR indicated Resident 1 slept seven hours over a 72-hour period from 9/5/23 to 9/7/23 and 13 hours over a 120-hour period from 9/13/23 to 9/17/23. The MAR indicated Resident 1 only slept for two hours over a 48-hour period (two days) from 9/29/23 to 9/30/23. Page 1 of 2 555287 555287 11/01/2023 Diamond Ridge Healthcare Center 2351 Loveridge Road Pittsburg, CA 94565

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 1's MAR for October 2023, the MAR indicated Resident 1 slept for four hours over a 72-hour period from 10/5/23 to 10/7/23. The MAR indicated Resident 1 had one hour of sleep over an 88-hour period from 10/12/23 to 10/18/23, with zero hours of sleep from 10/12/23 to 10/14/23 (more than two days) and only sleeping an hour on 10/15/23 during the day shift, and zero hours for the evening and night shift. The MAR also indicated, on 10/24/23, Resident 1 only slept for two hours during the morning shift from 7:00 am to 3:00 p.m. and did not sleep from 3:00 p.m. until 11 p.m. the following day on 10/25/23. During review of Resident 1's SBAR (Situation, Background, Appearance, Review, a structured communication framework that help health care teams share information among themselves), Resident 1's SBAR indicated the following: -On 10/4/23 at 2:05 a.m., Resident 1 was found sitting on the floor in the room. -On 10/21/23 at 7:55 p.m., Resident fell during a struggle with a staff while in the hallway. -On 10/27/23 at 11:00 p.m., Resident fell on the floor while walking on the hallway unassisted. Resident 1 attempted to hit the staff twice for trying to help. -On 10/29/23 at 11:30 p.m., Resident 1 slipped on the floor while up in the wheelchair in front of the nurses' station. -On 10/24/23 at 5:40 p.m., Resident was violent towards the staff and refused to sit in the wheelchair. Resident 1 lost balance and fell when Resident 1 attempted to hit a CNA. During a concurrent interview and record review on 11/1/23 at 1:37 p.m. with Director of Nursing (DON), Resident 1's MAR for October 2023 and clinical records were reviewed. DON stated Resident 1's lack of sleep could have affected his behavior. DON stated when Resident 1 was not able to sleep for 48 hours, the physician should have been notified so that appropriate re-evaluation could be done. DON stated the clinical record did not indicate that Resident 1's physician was notified of Resident 1's inability to sleep. During a telephone interview on 11/3/23 at 3:57 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 received Temazepam and melatonin every evening and number of hours of sleep was monitored each shift to evaluate the efficacy of these medications. RN 1 stated she entered the number of hours for the evening shift in the MAR but was not able to see the screens for the other two shifts. RN 1 also stated Resident 1 rarely slept during the evening shift but did not know that Resident 1 did not sleep during the day and nights shifts too. During a telephone interview on 11/3/23 at 11:03 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 did not sleep most nights. LVN 1 stated when Resident 1 was up all night, he was usually very hard to re-direct, went in and out of bed, walked in the hallway, screamed, yelled, and became very aggressive towards the staff. LVN 1 stated when Resident 1 did not sleep the entire night shift, LVN 1 would enter zero (0) on the sleep monitoring page in the MAR. LVN 1 also stated not notifying the physician of Resident 1's inability to sleep during the night shift. 555287 Page 2 of 2