Health inspection·August 23, 2019

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 3's MDS, dated [DATE], indicated he required extensive assistance (staff provide weight-bearing support) from two or more people for transfers. The MDS also indicated the bed rail was coded as a physical restraint for Resident 3. Residents Affected - Some During an observation on 8/22/19 at 10:30 a.m., Resident 3 was sitting on his chair in his room. His bed was equipped with partial bed rails (rails that did not cover the entire length of the bed). He was unable to move his left arm and left leg. During an interview with MDSN B and MDSN C on 8/23/19 at 12:43 p.m., they both confirmed Resident 3's bed rails were not restraints because he could not voluntarily get out of bed, even if the bed rails were not present. 5. Review of Resident 10's MDS, dated [DATE], indicated she required extensive assistance from one person for transfers. The MDS also indicated the bed rail was coded as a physical restraint for Resident 10. During an observation and concurrent interview with Resident 10 on 8/21/19 at 1:56 p.m., Resident 10 was sitting on her chair in her room. Her bed was equipped with short rails near the head of the bed. Resident 10 stated the short rails helped her move and did not restrain her. During an interview with MDSN B and MDSN C on 8/23/19 at 12:39 p.m., they both confirmed the short rails near the head of Resident 10's bed were not restraints. MDSN B and MDSN C also confirmed Resident 10 could not voluntarily get out of bed, even if the bed rails were not present. 6. Review of Resident 30's MDS, dated [DATE], indicated he required extensive assistance from two or more people for transfers. The MDS also indicated the bed rail was coded as a physical restraint for Resident 30. During an observation and concurrent interview with Resident 30 on 8/21/19 at 8:30 a.m., Resident 30 was lying in his bed, which was equipped with partial rails. Resident 30 stated the bed rails helped him move and did not restrain him. During an interview with MDSN B and MDSN C on 8/23/19 at 12:42 p.m., they both confirmed Resident 30's bed rails were not restraints because he could not voluntarily get out of bed, even if the bed rails were not present. 7. Review of Resident 42's MDS, dated [DATE], indicated she required extensive assistance from one Page 1 of 7 555835 555835 08/23/2019 VI at Palo Alto 600 Sand Hill Road Palo Alto, CA 94304

F 0641 person for transfers. The MDS also indicated the bed rail was coded as a physical restraint for Resident 42. Level of Harm - Minimal harm or potential for actual harm During an observation and concurrent interview with Resident 42 on 8/21/19 at 8:53 a.m., Resident 42 was lying in her bed, which was equipped with short rails near the head of the bed. Resident 42 stated the short rails helped her move and did not restrain her. Residents Affected - Some During an interview with MDSN B and MDSN C on 8/23/19 at 12:45 p.m., they both confirmed the short rails near the head of Resident 42's bed were not restraints. MDSN B and MDSN C also confirmed Resident 42 could not voluntarily get out of bed, even if the bed rails were not present. Review of the RAI manual indicated a device should be classified as a restraint only when it meets the criteria of the restraint definition. The RAI manual further indicated, If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. Based on observation, interview, and record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) for seven of 12 sampled residents (Residents 16, 19, 41, 3, 10, 30, and 42). For Resident 16, the facility inaccurately coded the use of a medication. For Residents 19, 41, 3, 10, 30, and 42, the facility inaccurately coded bed rails as physical restraints. Failure to accurately assess the residents had the potential for inappropriate care planning and interventions. Findings: 1. Review of Resident 16's MDS' dated 9/22/18, 12/23/18, 3/25/19, and 6/25/19 under Section M Medications, indicated Resident 16 received anticoagulant (blood thinner, medication that slows down clotting). Review of Resident 16's physician order report indicated an order for Plavix (clopidogrel, antiplatelet medication that prevents clots from forming and growing) 75 milligrams once a day for stroke prevention. During an interview with minimum data set nurse B (MDSN B) on 8/23/19 at 10:59 a.m., MDSN B stated they thought Plavix was an anticoagulant. MDSN B confirmed Resident 19 was not on an anticoagulant but was an antiplatelet medication. 2. Review of Resident 19's clinical record indicated diagnoses of muscle weakness, difficulty in walking, restless leg syndrome, and reduced mobility. Review of Resident 19's MDS dated [DATE] under Section P Restraints and Alarms, indicated the bed rail was used daily as a physical restraint for Resident 19. Under Section G Functional Status, it indicated Resident 19 needed extensive assistance with two or more person assist for bed mobility and transfers. Review of Resident 19's physician orders report dated 7/10/18, indicated an order that Resident 19 may use quarter side rails as enablers for assistance with transfers, bed mobility and aid in position while at the facility. 555835 Page 2 of 7 555835 08/23/2019 VI at Palo Alto 600 Sand Hill Road Palo Alto, CA 94304

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation and interview on 8/20/19 at 10:07 a.m., Resident 19 was in bed with one side rail up. Resident 19 stated the side rail was to help her move around in bed. Resident 19 stated she was able to move around once in the wheelchair but needed help with transferring. During an interview with the registered nurse supervisor (RNS) on 8/23/19 at 11:37 a.m., the RNS stated Resident 19 was unable to physically get out of bed by herself and needed two people to physically get Resident 19 out of bed to a wheelchair. During an interview with MDSN B and MDSN C on 8/23/19 at 12:31 p.m., MDSN B and MDSN C confirmed Resident 19 was not able to get out of bed by herself with or without the side rail present. 3. Review of Resident 41's clinical record indicated the diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), Parkinson's disease (loss of nerve cells in the brain affecting movement), muscle weakness and difficulty in walking. Review of Resident 41's MDS dated [DATE] under Section P Restraints and Alarms indicated the bed rail was used daily as a physical restraint for Resident 41. Under Section G Functional Status, it indicated Resident 41 needed extensive assistance with two or more person assist for bed mobility and transfers. Review of Resident 41's physician orders report dated 7/31/19 indicated an order that Resident 41 may use quarter side rails as enablers for assistance with transfers, bed mobility and aid in position while at the facility. During observation and interview on 8/20/19 at 1:46 p.m., Resident 41 was observed lying in bed with two side rails up on both sides of the bed. During another observation and interview on 8/23/19 at 8:23 a.m., Resident 41 was lying in bed with two side rails up on both sides of the bed. Resident 41's family member was also at bedside. Resident 41 stated the side rail does not restrain me at all. Resident 41 stated he was not able to physically get out of the bed by himself. During an interview with registered nurse D (RN D) on 8/23/19 at 11:39 a.m., RN D stated Resident 41 was not able to get out of the bed by himself and needed at least a two person assist to get out of bed and into a wheelchair due to Resident 41's condition. During an interview with MDSN B and MDSN C on 8/23/19 at 12:31 p.m., MDSN B and MDSN C confirmed Resident 41 was not able to get out of bed by himself with or without the side rail present. Review of the Minimum Data Set 3.0 Resident Assessment Instrument User's Manual version 1.16 (RAI manual, MDS coding instructions) dated 10/2019 indicated if the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive device were not present, the bed rails do not meet the definition of a physical restraint. 555835 Page 3 of 7 555835 08/23/2019 VI at Palo Alto 600 Sand Hill Road Palo Alto, CA 94304

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 observation, interview and document review, the facility's pharmacy failed to ensure there was no expired medication in one of three emergency kits (E-kits). This failure had the potential to result in residents receiving medication with decreased potency. Findings: During an observation on 8/20/19 at 10:30 a.m., the facility's E-kit for intravenous (IV, administered into a vein) medications was inspected. Inside the E-kit, there was one vial (small cylindrical container) of Vancomycin Hydrochloride (medication used to treat infection) 1 gram (gm, unit of dose measurement) with an expiration date of 8/1/19. During a concurrent interview with registered nurse A (RN A), she confirmed the vial of Vancomycin Hydrochloride 1 gm was expired. RN A confirmed the expired medication should not have been in the E-kit. During an interview with the consultant pharmacist (CP) on 8/21/19 at 2:24 p.m., he explained that the pharmacist who stocked the E-kit before it was sent to the facility was supposed to check the expiration dates on the medications. Review of the facility's policy, Medication Storage in the Facility ID1: Storage of Medications, revised 3/4/14, indicated All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. 555835 Page 4 of 7 555835 08/23/2019 VI at Palo Alto 600 Sand Hill Road Palo Alto, CA 94304

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to monitor for side effects of psychotropic medications (medications capable of affecting the mind, emotions and behavior) for one of eight sampled residents (Resident 30). This failure had the potential to negatively affect the resident's health and well-being. Findings: Review of Resident 30's clinical record indicated he had the diagnoses of Parkinson's disease (progressive disorder of the nervous system), dementia (disorder of the mental processes caused by brain disease or injury) and major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 30's physician's order, dated 7/16/19, indicated he was to receive Seroquel (an antipsychotic medication) 12.5 milligrams (mg, unit of dose measurement) by mouth at bedtime for Parkinson's related psychosis (a severe mental disorder) manifested by visual hallucinations (seeing things that are not really there) and aggression. Resident 30 also had a physician's order, dated 6/27/19, for Lamotrigine (anticonvulsant medication sometimes used to treat mood disorders) 100 mg by mouth once an evening for depression manifested by statements of having a low mood. There was no documentation indicating staff had been monitoring Resident 30 for side effects of Seroquel or Lamotrigine. During an interview and concurrent record review with minimum data set nurse B (MDSN B) on 8/23/19 at 9:14 a.m., she stated staff should monitor for side effects of psychotropic medications every shift. She further stated the monitoring should be documented on the medication administration record (MAR). MDSN B reviewed Resident 30's record and confirmed there was no documentation indicating staff had been monitoring him for side effects of Seroquel or Lamotrigine. During an interview with the consultant pharmacist (CP) on 8/23/19 at 10:56 a.m., he stated monitoring for side effects of psychotropic medications should be documented on the MAR. Review of the facility's policy, Preparation and General Guidelines IIIA3: Limitations on Psychoactive Drugs, revised 1/18/18, indicated Interdisciplinary team [IDT, staff from different disciplines who work together to plan and provide care] will work together to ensure appropriate use, evaluation and monitoring. The policy further indicated, Facility staff will monitor psychotropic medication use and note adverse effects or changes in resident behavior and report to provider. 555835 Page 5 of 7 555835 08/23/2019 VI at Palo Alto 600 Sand Hill Road Palo Alto, CA 94304

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility had an eight percent medication error rate when two medication errors out of 25 opportunities were observed during medication pass for two of five residents (Residents 20 and 95). These failures had the potential to compromise the health and safety of the residents. Residents Affected - Few Findings: 1. Review of Resident 20's clinical record indicated she had a physician's order, dated 3/16/19, for Klor-Con 10 (potassium chloride, a mineral supplement) extended release (ER, designed to slowly release the medication in the body over an extended period of time) tablet 10 milliequivalents (meq, unit of dose measurement) two tablets by mouth once a morning. During an observation on 8/22/19 at 9:37 a.m., licensed vocational nurse E (LVN E) crushed two tablets of the above medication, mixed the crushed tablets in applesauce, and administered them to Resident 20. During an interview with LVN E on 8/22/19 at 9:49 a.m., she confirmed she crushed the two tablets of potassium chloride ER and administered them to Resident 20. During an interview with the consultant pharmacist (CP) on 8/22/19 at 9:57 a.m., he stated potassium chloride ER should not be crushed. The CP explained that crushing the medication could alter its bioavailability (the degree and rate at which the medication is absorbed). Review of the facility's policy, Medication Crushing Guidelines, revised 3/4/14, indicated Timed Release Tablets are designed to release medication over a sustained period, usually 8 to 24 hours. The policy further indicated these tablets should not be crushed. The facility's 2019 Do No Crush Medication List was reviewed. Potassium chloride was on the list. 2. Review of Resident 95's clinical record indicated she had a physician's order, dated 8/5/19, for Refresh Tears (carboxymethylcellulose sodium, lubricating eye drops) 0.5% (concentration of the medication) one drop to both eyes twice a day. During an observation on 8/22/19 at 8:20 a.m., registered nurse D (RN D) administered one drop of artificial tears 0.2-0.2-1% to both of Resident 95's eyes. During an interview with RN D on 8/22/19 at 8:55 a.m., she confirmed the eye drops she administered to Resident 95 did not match the physician's order. RN D also confirmed that prior to administering the eye drops, she did not check to make sure the eye drop concentration matched the physician's order. During an interview with the CP on 8/22/19 at 9:57 p.m., he explained that Refresh Tears 0.5% and artificial tears 0.2-0.2-1% were slightly different from each other. Review of the facility's policy, Preparation and General Guidelines IIA2: Medication Administration-General Guidelines, revised 3/4/14, indicated Medications are administered in accordance with written orders of the prescriber. The policy further indicated a triple check of the five rights (right 555835 Page 6 of 7 555835 08/23/2019 VI at Palo Alto 600 Sand Hill Road Palo Alto, CA 94304

F 0759 resident, right drug, right dose, right route and right time) is recommended in the process of preparation of a medication for administration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555835 Page 7 of 7