Health inspection·January 25, 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 observation, interview, and record review, the facility failed to ensure one resident ' s (Resident 2) controlled medications were secured and disposed of after discharge to the hospital. This deficient practice had the potential to result in drug diversion. Findings: Review of Resident 2 ' s admission Record indicated Resident 2 was admitted on [DATE] to facility with diagnoses including: Sepsis (widespread infection), Acute Respiratory Failure with Hypoxia (Difficulty breathing), and Opioid (pain medication) Dependence. Review of Resident 2 ' s Medication Administration Record (MAR) indicated that Resident 2 received Hydromorphone HCL (Narcotic Pain Medication) 3 x 8 Milligrams(MG) tablets every 6 hours for Chronic Pain and Alprazolam(Anti-anxiety medication) and 1x O.5 MG tablet once a day in the morning for anxiety. On 1/9/24 at 10:30 A.M., an interview with Administrator (ADM) was conducted. ADM stated facility investigation found the following: All of Resident 2 ' s medication were held in the medicine cart including narcotics at the time of discharge on [DATE]. On 12/22/23, Licensed Nurse (LN) 1 made a note on narcotics to hold the medications in anticipation of Resident 2 ' s return and placed note with medications in narcotic box in medication cart. LN 1 went on vacation from 12/22/23 to 12/26/23 and when she returned the medication was not there. Resident 2 returned to facility on 12/30/23, but never missed medication according to ADM. LN 1 reported medications missing on 1/5/24 to ADM, and investigation was done. ADM stated that the facility ' s investigation found all the Resident 2 ' s medication was gone, narcotics and regular medications. ADM stated that all nurses assigned to that medication cart were interviewed, and no one had a memory of the medication being stored there. ADM stated a nursing in-service was done on 1/5/23 the same day medication was discovered missing. ADM stated that the narcotic sheet was revised to include documenting the narcotic count, and the count of resident ' s medication cards. On 1/9/24 at 10:50 A.M., an interview with LN 1 was conducted. LN 1 stated that she normally worked with Resident 2. LN 1 stated that if a resident was discharged to a hospital, the LN should give the medications to the Director of Nursing (DON) to be destroyed. LN 1 stated that it was best practice on the Long-Term Care unit to keep medications in the cart if a resident was discharged to the hospital for a short term stay, 2-3 days, as it often took a long time to get the medications when they returned. LN 1 stated Resident 2 was discharged on 12/17/23 and Resident 2 ' s medications were Page 1 of 4 555873 555873 01/25/2024 South Bay Post Acute Care 553 F Street Chula Vista, CA 91910

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bundled and put behind the active resident ' s medications in the locked drawer of medication cart. LN 1 stated on 12/22/23 she received a call from hospital that Resident 2 would be returning to facility in a few days. LN 1 stated she put a note on Resident 2 ' s medication to hold it there in anticipation of Resident 2 returning from the hospital. LN 1 stated she reported to the night shift (NOC) nurse that she would be coming back and to hold Resident 2 ' s medication in the cart. LN 1 stated that she thought at that time that the best practice would be to keep the medications in the cart. LN 1 stated she estimated there were 30-40 pills of oxycodone left when she last saw them. LN 1 stated the last time she saw the pills was on 12/22/23 at 3:30 P.M. LN 1 stated when she came back to work on 12/26/23 and the medication was not there, so she checked with the Director of Staff Development (DSD) who was the DON Designee (Acting DON) at the time, if the medications were destroyed. LN 1 stated DSD did not know Resident 2 ' s medications were in the cart after discharge and had not destroyed any medication that month. LN 1 stated that the policy and procedure for drug storage/disposal when a resident is discharged to the hospital was to turn the narcotics into the DON or DON designee within 24 hours for storage and destruction. LN 1 stated the importance of turning in discharged patient ' s controlled medication was to prevent drug diversion. On 1/9/24 at 11:55 A.M. a concurrent observation of medication cart, review of MARs and interview with LN 2 was conducted. A review of the LN 2 ' s process for controlled medications administration and storage was reviewed for Resident 2, Resident 4, and Resident 5. LN 2 stated that if a resident is discharged the controlled medications should be given to the DON for storage prior to destruction. LN 2 stated that she would not hold onto medications when a resident is discharged . LN 2 stated that if the medications were held onto after a resident ' s discharge, they could be taken or lost. On 1/9/24 at 12:50 P.M, an interview was conducted with the DSD. DSD stated that a report from LN 1 was made about Resident 2 ' s controlled medications after LN 1 discovered they were missing. Resident 2 was re-admitted [DATE] and the licensed nurse could not find her original medications. The DSD stated that when Resident 2 was discharged to hospital, the LN is supposed to give the narcotics to the DON /DON designee, and the DON/ DON designee will put the controlled medications in the safe box in her office until the pharmacist comes in to do the destruction of controlled medications with the DON. DSD stated when controlled medications are destroyed, it is recorded in a log. DSD stated that there was no record of Resident 2 ' s narcotics being destroyed by DON and the Pharmacist. DSD stated the LN should have given the narcotics to DON for destruction when Resident 2 was discharged to hospital. DSD stated the importance of giving narcotics to DON when a resident is discharged to the hospital, is to prevent someone from taking the controlled medications of that resident. On 1/10/24 at 7:45 A.M., an interview was conducted with LN 3. LN3 stated he was the night shift nurse the day that Resident 2 was discharged . LN 3 stated that on the night of 12/22/23, Resident 2 had already been discharged . LN 3 stated he had done the controlled substance count for the medication cart. LN 3 stated the count included Resident 2 ' s medication with outgoing evening nurse LN 4. LN 3 stated he was unsure if Resident 2 ' s controlled medications were there, and he thought they were included in the count. LN 3 stated that when a resident is discharged to the hospital, he will leave the medication bundled together in the medication cart in the back of the locked drawer of the medication cart, but remove the medication from the count sheet. LN 3 stated that discharged resident ' s controlled medications should be turned in to the DON or DON designee when possible. LN 3 stated that turning in narcotics to DON would prevent someone from taking the discharged resident ' s medication. 555873 Page 2 of 4 555873 01/25/2024 South Bay Post Acute Care 553 F Street Chula Vista, CA 91910

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/10/24 at 7:57 A.M. an interview with LN 4 was conducted. LN 4 stated that she was the nurse who discharged Resident 2 to the hospital that day on 12/17/23. LN 4 stated she remembered Resident 2 ' s medications all bundled in the back of the medication cart used for controlled medication. LN 4 stated they will typically count all the controlled medication in the drawer every shift including the medication for discharged residents. LN 4 stated she saw the bundle of medications that day after resident was discharged . LN 4 stated when Resident 2 was discharged to the hospital, the nurses usually will put the discharged resident ' s medication toward the back of the locked drawer, until they can give the medications to the DON/DON designee the medication to store prior to destruction by DON and pharmacist. LN 4 stated that an accepted practice on the Long-Term Care/Custodial side of the facility was that nurses keep the medication in cart when the discharged resident is expected to come back to the facility in 2-3 days from hospital. LN 4 stated this is an, accepted practice because it can take up to 4-8 hours to get medications from the pharmacy. LN 4 stated the importance of giving medications to DON after discharge is to prevent controlled medication from being misplaced or taken. On 1/10/24 at 10:19 A.M., an interview with the Pharmacy Consultant (PC) was conducted. PC stated that the expectation is to keep the controlled medication available, but in a secure area with limited access to controlled medication. PC stated that LN who discharged the resident should have given controlled medications to the DON to put in a secured lock box where they could be logged and stored until monthly destruction of narcotics by DON and PC. PC stated the importance of securely storing a discharged resident ' s controlled medication was to prevent drug diversion. On 1/10/24 at 10:45 A.M., an interview with LN 5 was conducted. LN 5 stated that the LN ' s on long term side usually hold controlled medication in the locked drawer in medication cart for 2-3 days or when the resident is expected to come back from the hospital, and medication is still counted in the count. LN 5 stated the expectation was that they would give the medication to the DON for storage before destruction after waiting the 2-3 days. LN 5 stated that she thought the policy was to give the controlled medication to the DON after the resident was discharged . LN 5 stated holding the controlled medications of a discharged resident was a practice they did on the long term/custodial side of the facility, and that they did it mainly because it took a long time to get medications on re-admission. LN 5 stated the importance of giving a discharged resident ' s controlled medication to the DON in timely manner was to prevent drug diversion. On 1/25/24 at 9:36 A.M. an interview with DON was conducted. DON stated that the expectation was the LNs should have turned the medication in to her for locked storage in her office prior to destruction as soon as they could. DON stated that if resident was discharged on a weekday, the LN could give controlled medications that day, or if discharged on night shift, by the next morning. DON stated if resident discharged on a Friday night or over weekend, the LN should turn the controlled medications into her by Monday morning. A review of day of discharge (12/17/23) and day of reporting missing medication (1/5/24) was conducted with the DON. The DON stated that this was an unacceptable practice. DON stated that the importance of timely disposition of discharged resident ' s controlled medication was to prevent drug diversion. Review of policy entitled Narcotic Count dated 2023, indicated .III. Disposal of Medication .2. Medications that are Discontinued by the physician and are controlled medications, will be removed from the eMAR, physically removed from the medication cart after being counted and signed by two staff members, then given to the Director of Nursing/Designee for storage until destruction occurs . 555873 Page 3 of 4 555873 01/25/2024 South Bay Post Acute Care 553 F Street Chula Vista, CA 91910

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of policy entitled Medication Storage in the Facility dated January 2022, indicated .IE1: Controlled Substance Disposal .C. All controlled substances remaining in the facility after a resident has been discharged or the order is discontinued, as disposed of 1) In the facility by the director of nursing and/or consultant pharmacist Residents Affected - Few 555873 Page 4 of 4