Health inspection·September 4, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an ordered medication from its contracted pharmacy for one resident (1), who had comfort care (care given to people who are near the end of life) orders. As a result, Resident 1 did not receive the ordered medication to provide comfort prior to his passing (dying). Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure (a condition in which the kidneys lose their ability to filter waste from the blood), pneumonia (an infection that affects the lungs), COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease that causes breathing problems), heart failure (a condition in which the heart does not pump enough blood for the needs of the body), Parkinson ' s disease (a brain disorder that causes uncontrolled movements such as shaking, stiffness and difficulty with balance), and Alzheimer ' s Disease (a progressive irreversible brain disorder that affects memory, thinking and language). On 7/31/24 the State Agency (SA) received a complaint which indicated Medical Doctor (MD) 1 determined (Resident 1) was at the end of his life, and ordered morphine (an opiate narcotic pain reliever) for comfort care. At approximately 11:30 A.M., Registered Nurse (RN) 1 confirmed that MD 1 ordered morphine (for Resident 1) and that she would administer it (the morphine) soon. Resident 1 passed away at approximately 2:30 P.M. and never received the morphine. On 8/13/24 at 11:30 A.M. an interview and concurrent medical record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated, (Resident 1) was prescribed a comfort pack like hospice (comfort and quality of life care provided to a person with a serious illness who is approaching the end of life) patients. There was an order for morphine liquid every hour as needed for pain and shortness of breath, Levsin (a medication to help decrease saliva) and Ativan (a medication to help decrease anxiety) every four hours. An interview with the ADON was conducted on 8/22/24 at 15:45 P.M. The ADON stated, There is no documentation that the pharmacy was contacted to release the medication. I was not aware there was a problem getting the medication. I probably should have just helped them out more. None of the ordered medications were administered. Ativan was in the emergency kit (a collection of medications available in urgent circumstances) but was not given (to Resident 1) . The ADON referred to a facility docuement that indicated, Pharmacy will perform deliveries at least three (3) times per day, 7 days a week, Monday through Sunday. Pharmacy will also provide emergency deliveries as requested by Facility. Page 1 of 2 555425 555425 09/04/2024 Vista Knoll Specialized Care Facility 2000 Westwood Road Vista, CA 92083

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ADON stated there was no evidence to prove the facility requested emergency delivery of the morphine solution. On 8/23/24 at 3:51 P.M. an interview was conducted with the Director of Nursing (DON) who stated, The standard of care is to make sure the resident is comfortable. Whatever medication was ordered by the physician should be given. It would actually help the resident to have the medication, at least the Ativan that was in the facility. On 8/26/24 at 11:33 A.M., an interview was conducted with RN 1 who stated, The doctor ordered the medications to make (Resident 1) comfortable. The Ativan was in the emergency kit . I did not offer the Ativan. On 8/27/24 at 8:50 A.M. a telephone interview was conducted with the owner of the contracted facility pharmacy who stated, The morphine order was faxed (facsimile; method of transmitting scanned material or text via telephone line) to us. There was no physician signature and no quantity. We received it on 7/28/24 12:53 P.M. from the facility, not the prescriber, and went into our queue (order list of messages). (MD 2) instructed the pharmacy not to contact via phone on weekends, but to contact the answering service or use eScript (a digital version of a prescription for medication). We sent an eScript at 1:56 P.M. The assumption is that if the physician wants something sent electronically hopefully someone is monitoring. For an urgent need we would need to get a phone call from the facility to alert us. I don ' t have any notes that the facility alerted us. If it ' s a phone call that came in, we just take care of it, we don ' t document it. There ' s no indication on the fax that the medication was urgently needed. A review of the facility policy titled, Provider Pharmacy Requirements effective January 2022 indicated, Regular and reliable pharmaceutical services is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies.The provider pharmacy is responsible for rendering the required service in accordance with local, state, and federal laws and regulations; facility policies and procedures; community standards of practice; and professional standards of practice. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to: .accurately dispensing prescriptions based on authorized prescriber orders.Providing routine and timely pharmacy service as contracted, and pharmacy service 24 hours per day, seven days per week. An interview was conducted with the DON on 8/26/24 at 4:22 P.M. The DON stated that the Ativan should have been given. Further, the DON stated, Nobody called the pharmacy to speed up the process of releasing the morphine. The medications were not given, the needs of the resident were not met. 555425 Page 2 of 2