Health inspection·August 27, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure a licensed vocational nurse (LVN 1) administered medication accurately and safely to one of two sampled residents (Resident 1) according to the physician orders when Bengay cream (used to treat minor aches and pains of the muscles/joints) was administered instead of a skin barrier cream on Resident 1 ' s moisture associated skin damage (a form of incontinence-associated dermatitis, which is inflammation of the skin from extended exposure to urine or stool). This failure resulted in pain and discomfort for Resident 1. Findings: A review of the admission Record for Resident 1 indicated Resident 1 was initially admitted in March 2018 with diagnoses that included dementia, diabetes, asthma, and osteoarthritis. A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/14/24, indicated a score of 3 on her Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information.) indicating severe cognitive impairment. The MDS for Resident 1 ' s skin conditions indicated Moisture Associated Skin Damage (MASD) (e.g. incontinence-associated dermatitis (IAD), perspiration, drainage). During an interview on 8/27/24 at 1:35 p.m. with Director of Nursing (DON), DON stated LVN 1 had a medication error by administering Bengay cream on Resident 1. DON stated Coloplast Critic-Aid cream, a barrier cream, was supposed to be applied on Resident 1. During a telephone interview on 8/27/24 at 5:18 p.m. with LVN 1, LVN 1 confirmed that he made an error of wrong medication to Resident 1. LVN 1 stated he handed Bengay cream instead of the barrier cream to CNA 1 to apply on Resident 1 ' s skin on her buttocks, while CNA 1 and another CNA were changing Resident 1. LVN 1 stated he was present there during the time. LVN 1 stated Resident 1 experienced pain and burning sensation in the buttock area. LVN 1 stated he knew afterwards that it was Bengay cream that was applied on Resident 1 instead of the barrier cream (Coloplast critic-aid). During a telephone interview on 8/28/24 at 9:20 a.m. with CNA 1, CNA 1 stated while she was changing Resident 1 with the help of another CNA on 8/8/24 after dinner, LVN 1 gave her the cream in a medicine cup to apply on Resident 1 ' s skin. CNA 1 stated she put the cream on Resident ' s groin area, then she smelt something like menthol, then Resident 1 complained of burning in that area. CNA 1 Page 1 of 2 555421 555421 08/27/2024 Stonebrook Post Acute 4367 Concord Boulevard Concord, CA 94521

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she asked LVN 1 what the cream was. LVN 1 stated they found out it was Bengay cream, but it was supposed to be the barrier cream. During a review of Resident 1 ' s Order Summary Report, dated active orders as of 8/27/24, the Order Summary Report indicated Moisture Associated Skin Dermatitis on sacrococcygeal region (tailbone area), gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum), opposing medial buttock region: Apply Coloplast Critic-Aid barrier cream every shift and as needed for episodes of incontinence (May apply Clotrimazole 1% antifungal cream on natal/gluteal cleft for skin erythema) . order date 6/4/24. The Order Summary Report indicated Bengay (ultra strength external cream 4-10-30% (Camphor-menthol-methyl salicylate). Apply to both knees and shoulders topically every 6 hours as needed for pain related to primary osteoarthritis, left shoulder, right ankle, and foot, left ankle and foot. During a review of the Medication Error Report. dated 8/8/24, the Medication Error Report indicated Bengay external topical cream was given to Resident 1 instead of Coloplast Critic-Aid barrier cream as ordered, and this caused Resident 1 pain/burning sensation in the affected area. During a review of the facility ' s policy and procedure (P&P), titled, Administration of Medication, undated, the P&P indicated, The policy .is that medications will be administered by licensed nurses as ordered by the resident ' s physician .Residents shall receive their medications . and in accordance with our established policies .The same person preparing the doses for administration must administer medications. 555421 Page 2 of 2