Health inspection·May 9, 2019

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a monthly Medication Regimen Review (MRR, is the process of identifying and addressing significant medication issues at the time the resident is admitted to the facility) was done for four of four sampled residents (Resident 7, 9, 5, and 18) when: 1. For Resident 7, the MRR was not done for the months of March and April 2019; 2. For Resident 9, the MRR was not done for the month of February 2019; 3. For Resident 5, the MRR was not done for the month of April 2019; 4. For Resident 18, the MRR was not done for the month of April 2019. This failure had the potential for inadequate monitoring and missed medication recommendations that could affect the health and safety of the residents. Findings: 1. A review of Resident 7's admission facesheet (Resident's demographic information) indicated Resident 7 was admitted on [DATE], with diagnoses that included chronic kidney disease, stage 3 dementia (a condition that affects the elderly's memory and their ability to process information), visual hallucinations, age-related physical debility, essential [primary] hypertension (high blood pressure) and atherosclerotic heart disease (hardening of the heart vessel). During a review of Resident 7's physician orders sheet, dated May 9, 2019, indicated the following medications: a. Tramadol 50 mg [milligram- unit of measurement] tab [tablet] PO [per os- by mouth] Q [every] 6 hrs [hour-frequency in time] PRN [pro re nata- as needed] for pain; b. Acetaminophen tab 650 mg PO Q6H PRN for breakthrough pain; c. Risperidone tab 1 mg PO BID [bis in die- twice a day] for behavioral disturbance related to dementia; d. Melatonin cap [capsule]/tab 9 mg PO bedtime for insomnia; Page 1 of 6 555527 555527 05/09/2019 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0756 e. Sulfamethoxazole 800/Trimeth 160 mg 1 tablet PO BID X 7 days for UTI [urinary tract infection]; Level of Harm - Minimal harm or potential for actual harm f. Bisacodyl sup [suppository], RTL [rectal] 10 mg RTL PRN Administer if no BM [bowel movement] 3 days; Residents Affected - Few g. Mineral Oil Enema 135 ml [milliliters- unit of measurement] the contents of 1 bottle RTL PRN if no BM in 4 days for constipation notify MD if ineffective for further treatment; and, h.Trazodone 50 mg PO bedtime for depression. A review of Resident 7's clinical records, indicated there was no documented evidence that a monthly medication regimen review was done for the months of March 2019 and April 2019. During an interview with the facility's Pharmaceutical Consultant (PC) on May 8, 2019, at 12:21 PM, he stated that the monthly medication regimen review is usually done on the 20th of each month. The PC verified that he had not done some residents' medication regimen reviews and that included Resident 7. The PC acknowledged that resident's MRR should be done in a timely every month to identify medication side effects, if medication is effective, if medication had interactions with other resident's medication or if there is a duplicate therapy (medication of the same effect). 2. A review of Resident 9's admission facesheet indicated Resident 9 was admitted on [DATE], with diagnoses that included age-related physical debility, essential [primary] hypertension, paroxysmal atrial fibrillation (irregular heartbeat), benign prostatic hyperplasia (enlarged prostate), dysphagia, (difficulty swallowing), unspecified fracture of second lumbar vertebra ( fracture of the back), constipation, repeated falls, iron and age-related osteoporosis (a condition in which bones become brittle and weak). During a review of Resident 9's physician order sheet, dated May 9, 2019, indicated the following: a.Acetaminophen tab 650 mg PO Q6 hrs PRN for pain 1-4 pain scale; b.Potassium Chloride 20meq [millequivalent- unit of measurement]/15 ml [milliliters- unit of measurement] liquid PO daily for hypokalemia (low potassium); c. Pantoprazole tab EC [enteric coated] 40 mg PO QPM [every afternoon] for GERD [gastroesophageal reflux disease]; d. Ascorbic Acid tab 500 mg PO Daily for aid in iron absorption; e. Docusate NA [Sodium] 50 mg/5 ml liquid PO QPM; f. Magnesium hydroxide 1200 mg/15 ml susp [suspension] 15 ml PO daily PRN for constipation; g. Lorazepam tab 0.5 mg PO bedtime for anxiety/agitation; h.Docusate cap 100 mg PO QPM for constipation, i. Lactulose soln [solution] 10 gm[gram- unit of measurement]/30 ml PO daily for constipation; 555527 Page 2 of 6 555527 05/09/2019 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0756 j. Tramadol tab 50 mg PO PRN take 1 tab[tablet] Q 8 hrs; Level of Harm - Minimal harm or potential for actual harm k. Bisacodyl supp RTL 10 mg RTL PRN if no BM in 3 days for constipation, Iron cap 65 mg PO daily for anemia; Residents Affected - Few l. Metropolol Tartrate 25 mg tab PO BID take ½ tab for hypertension Hold for SBP[systolic blood pressure <100 or hr [heart rate] <55; m. Cholecalciferol (Vitamin D 3) cap 1000 units PO daily for Vitamin D deficiency; n. Cyanoconalamin 500 mcg [microgram- unit of measurement] PO daily take two tabs for Anemia; o. Rivaroxaban 15 mg PO daily for A-fib [atrial fibrillation- an abnormal rapid conduction of the heart]; p. Furosemide 40 mg PO QAM [every morning] for hypertensive chronic kidney disease; q. Fexofenadine 180 mg PO daily for allergies; r. Tadalafil 5 mg PO daily for hypertensive chronic kidney disease; s. Levothyroxine 0.05 mg PO QAM for hyperthyroidism; t. Loratidine 10 mg PO QAM for allergies; and, u. Tamsulosin cap 0.4 mg PO QPM take 2 capsules by mouth at bedtime for BPH [benign prostatic hyperplasia- an enlargement of the prostate]. During a review of Resident 9's medical chart, there was no documented evidence that a monthly medication regimen review was done for the month of February, 2019. 3. A review of Resident 5's admission facesheet indicated Resident 5 was admitted on [DATE], with diagnoses that included unspecified dementia, urinary tract infection, hypothyroidism ( low levels of thyroid hormones), type 2 diabetes mellitus (increase blood sugar) and atherosclerotic heart disease (hardening of the heart blood vessels). During a review of Resident 5's physician order sheet, dated May 9, 2019, it indicated the following medications: a. Lorazepam 0.5 mg PO BID (twice a day) for anxiety; b. Hydrocodone 5 mg/Acetaminophen 325 mg 1 tablet PO (by mouth) PRN Q4 hours for breakthrough pain; c. Hydrocodone 5mg/Acetaminophen 325 mg 1 tab PO BID at 10:00 and 20:00 (8:00 PM) for pain management. d. Albuterol 3/Ipatroprium 0.5 mg/3 ml INHL [inhalation] Q4H PRN 1 unit dose via nebulizer [a drug delivery device used to administer medication in the form of a mist inhaled into the lungs] for SOB [shortness of breath]; 555527 Page 3 of 6 555527 05/09/2019 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0756 e. Sertraline 50 mg PO Daily for depression; Level of Harm - Minimal harm or potential for actual harm f. Sennosides 8.6 mg tab PO daily for constipation; g. Metoprolol tartrate 25 mg 1 tab PO for blood pressure hold for HR<65 or SBP <110; Residents Affected - Few h. Quetiapine 25 mg PO BID for severe agitation; i. Levothyroxine 0.125 mg PO daily for hypothyroidism; j. Cranberry extract 1 cap/tab PO daily for chronic UTI; and, k. Donepezil 5 mg 1 tab PO bedtime for Dementia. During a review of Resident 5's medical chart, there was no documented evidence that a monthly medication regimen review was done for the month of April, 2019. 4. A review of Resident 18's admission facesheet indicated Resident 18 was admitted on [DATE], with diagnoses that included, Major depressive disorder, constipation, anxiety disorder, and gastro-esophageal reflux disease (overflow of stomach acid to the esophagus) During a review of Resident 18's physician order sheet, dated May 9, 2019, it indicated the following medications: a. Multivitamin with minerals 1 tab by mouth every day as supplement; b. Phenytoin Sodium extended 100 mg capsule by mouth twice daily for seizures; c. Acetaminophen 325 mg tab 2 tabs by mouth every 6 hours as needed for pain; d. Acetaminophen 325 mg tab 2 tabs by mouth every 6 hours as needed for fever; e. Senna 8.6 mg tablet twice daily as needed for constipation; f. Alprazolam 0.25 mg tablet 1 tab by mouth every 8 hours for anxiety; g. Paroxetine HCL [hydrochloric acid] 20 mg tablet take 1 tab by mouth every morning for depression; h. Quetiapine Fumarate 100 mg tablet take 1 tab by mouth twice daily for agitation; i. Quetiapine Fumarate 300 mg tab take 0.5 (150 mg) by mouth at bedtime for agitation; and, j. Trazodone 50 mg tab take 1 tab by mouth at bedtime for insomnia/agitation. During an interview with the Physician (MD) on May 9, 2019, at 1:14 PM, he stated it is important to conduct monthly medication regimen review (MRR) to ensure residents are safe to take the medications prescribed. He stated the pharmacist and nurses are expected to inform him of any changes in the resident's health condition, side effects, and effectiveness while taking prescribed medications. 555527 Page 4 of 6 555527 05/09/2019 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the facility's policy and procedure titled, Monthly Medication Regimen Review, dated February 2019, indicated, Policy: The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. MRR includes evaluating the resident's response to medication therapy, in order to promote the best outcome and prevent or minimize adverse consequences due to medication. Findings and recommendations are reported to director of nurses (DON), physician, and if necessary, the medical director and/or administration. 555527 Page 5 of 6 555527 05/09/2019 Southern Inyo Hospital D/P Snf 501 E Locust Lone Pine, CA 93545

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to perform handwashing when providing assistance to five of five sampled residents (Residents 7, 22, 19, 11, and 75). This failure had the potential to cause cross-contamination (spread of infection among residents and staff) which could compromise the health and well- being of the residents. Residents Affected - Some Findings: 1. During a dining observation on May 6, 2019, at 5:38 PM, Resident 7 was observed eating in the dining room, Table 1 and Resident 22 in Table 2. The Activities Director (AD) assisted Resident 7 while eating when Resident 22 called out and requested some salt. The AD stood up from Resident 7's table and assisted Resident 22. The AD opened a packet of salt and sprinkled it over Resident 22's food and went back to assist Resident 7. The AD was not observed to perform hand hygiene between these two residents. 2. During a dining observation on May 6, 2019, at 5:42 PM, Residents 19 and 11 were eating in Table 3 and both requested coffee. The AD stood up from Table 1 and assisted Residents 19 and 11 for a cup of coffee. The AD was not observed to perform hand hygiene between these residents. 3. During a dining observation on May 6, 2019, at 5:49 PM, Resident 75 was observed eating in Table 4 and asked for a cup of water. The AD left Table 3 and assisted Resident 75. The AD did not perform hand hygiene. During an interview with the AD on May 6, 2019, at 5:59 PM, he stated he did not perform hand hygiene in between residents. The AD acknowledged, he should wash his hands in between residents to avoid spread of infections. During an interview with the Director of Staff Development (DSD) on May 6, 2019 at 6:09 PM, she stated it is important to perform hand washing before assisting a resident and in between assisting residents to prevent spread of infection among residents and staff and staff to residents. A review of the facility's policy and procedure titled, Handwashing, dated September 2004, indicated, Policy: It is the policy of SIH [Southern Inyo Hospital] to thoroughly cleanse the hands with friction, soap, and water to control infection, to reduce transmission of organisms from resident to resident, from resident to staff, and from nursing staff to resident. 555527 Page 6 of 6