Health inspection·June 28, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy for one of three sampled residents (Resident 1) when informed consent was not provided by resident or representative prior to psychotropic medication was administered (medications that affects mind, emotion and behavior). Residents Affected - Few This failure resulted in Residents 1's representative rights to be violated and risks, benefits, adverse reactions and right to refuse the administration of the medication. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: senile degeneration of brain (mental deterioration, loss of intellectual ability), palliative care (specialized care for people with serious illness), unspecified dementia (impaired ability to remember, think or make decisions), anxiety (feeling of fear, feeling tense and restless), delirium (mental state of confusion, disoriented, and lack of awareness). During a concurrent interview and record review of Resident 1's with the Director of Nursing (DON), reviewed are as follows: 1. Physician Telephone Order (Hospice) Dated July 27, 2023, Medication Order: Haloperidol (antipsychotic medication used to treat certain types on mental disorders) LAC 5 mg/mL vial inject 1 mL IM every 6 hours as needed .Signed July 28, 2023. 2. Documents: Apple Valley Care Center, Facility Verification of Residents Informed Consent Psychotherapeutic Drugs of Prolonged Use of Device Dated July 27, 2023: Resident Representative as Charter Hospice [Name] Registered Nurse, Relationship: [Name] Registered .Nurse receiving Order [Name] Registered Nurse .doctor signature dated July 28, 2023. (No resident or Resident Representative (spouse) signature of consent noted). 3. Medication Administration Record (MAR) July 2023: Haldol injection 5mg/mL, inject 1 mL intramuscularly every 6 hours as needed for r/t agitation, Administered July 28, 2023, at 11:12 and 1754. During an interview with the Director of Nursing DON (DON), the DON stated, The hospice nurse told me she called the wife for Haldol consent. I will not give medication if there is not a verbal or a signed consent. The hospice nurse told me she was the one who called the wife to get the consent, but I see the document, she [the hospice nurse] signed on the wrong space, it has her name in the resident representative. When asked, based on this document reviewed does it state the wife was called Page 1 of 2 555476 555476 06/28/2024 Apple Valley Care Center 11959 Apple Valley Rd Apple Valley, CA 92308

F 0684 and a verbal consent was given? No, it has the hospice nurse on both lines on the consent form. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure titled, Verification of Informed Consent for Psychotherapeutic Medications revised May 2024, the policy and procedure indicated: Policy Statement: Each resident has the right to be free from psychotherapeutic drugs and, to provide informed consent before treatment with psychotherapeutic drugs. Informational materials concerning psychotherapeutic drugs. The facility will obtain a written informed consent for treatment using psychotherapeutic drugs and consent renewal every six months .Procedure 2. If the resident or resident's representative cannot sign the informed consent form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. The personal exam and the signatures of the prescriber, resident, or representative can be completed and signed using remote technology. 4.Signed written consent will be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the president's health record contains written informed consent with the required signatures. Residents Affected - Few 555476 Page 2 of 2