Health inspection·February 6, 2025

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number CA00935519. A Class AA citation was written. REGULATORY VIOLATIONS: Code of Federal Regulations, Title 42, Section 483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: California Code of Regulations, Title 22, Section 72311: Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (E) Any untoward response or reaction by a patient to a medication or treatment. California Code of Regulations, Title 22, Section 72313: Nursing Service - Administration of Medication and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (3) Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, shall be performed as required and the results recorded. California Code of Regulations, Title 22, Section 72523: Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/17/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident's death. As a result of the investigation, CDPH determined the facility failed to: 1. Monitor the vital signs (VS) which included blood pressure (BP), apical pulse (AP- a pulse point on the chest that gives the most accurate reading of a heart rate), and heart rate (HR-Pulse), according to physician's order for the following medications: a. Amiodarone HCL (Medication to treat/control very rapid and irregular pulse]) 200 milligrams (mg - unit of measurement) oral tablet a day for atrial fibrillation (A-Fib, serious medical condition of the heart: fast and irregular heartbeat) hold for apical pulse <60. Amiodarone dose was held or given with no documented apical pulse on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, and 12/9/2024. b. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 mg Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60. Dose was held with no documented BP or HR on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and 12/8/2024. Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/24, 11/28, and 11/29/2024. c. Spironolactone (Medication to treat/control HTN) oral tablet 25mg give 0.5 tab a day for congestive heart failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100. Dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and 12/8/2024. Spironolactone dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15, 11/17, 11/24, and 11/30/2024. d. Entresto (Medication for heart failure) 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. Entresto dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/25, 11/26, 12/1, 12/7, and 12/8/2024. Entresto Dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15, 11/17, 11/24, and 11/30/2024. 2. Follow the facility's Policy and Procedures (P&P) to monitor for potential adverse consequences by ensuring the licensed staff will not ignore or override when a severe drug to drug interaction (Adverse drug Reaction [ADR]- harmful or unpleasant reactions to a medication that can be life-threatening) when amiodarone and metoprolol were administered together which could have result in hypotension (low blood pressure), bradycardia (slow heart rate), cardiac arrest, and death. 3. Ensure that Resident 1 did not get an excessive dose of Lidoderm patch (medication to numbs the skin and reduces the sensation of pain) 5% topically (onto skin) by receiving two doses on 12/9/2024 at 8:13 AM and 12/9/2024 at 1:23 PM. As result, on 12/9/2024 at 9AM, Resident 1 received all the following medications: metoprolol, spironolactone, Entresto, amiodarone, and 2 doses of Lidoderm 5% patch. On 12/9/2024 at 1:20 PM, the facility discharged Resident 1 to the Assisted Living Facility (ALF- a facility for people who need help with daily care, but not as much help as a nursing home provides) via the facility provided non-emergency transportation. Upon arrival of Resident 1 to the ALF, resident was pronounced deceased/dead at 2:26PM on 12/9/2024. A review of Resident 1's Admission Record, indicated the facility admitted the resident on 10/24/24, with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib, essential HTN (high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/24/24, indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required "substantial/maximal assistance" (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated 10/24/2024, indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib hold for Apical pulse <60 (per pharmacy recommendation). b. Metoprolol Succinate ER Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. e. Lidoderm Patch 5% (Lidocaine) apply to left thigh topically one time a day for pain management and remove per schedule. The order did not indicate what the schedule was. A review of Resident 1's Progress Notes for 10/2024, indicated medication administration orders had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL on 10/24/2024 at 8:37 PM, 10/27/2024 at 10:29 AM, 10/30/2024 at 2:38 PM, 10/30/2024 at 4:08 PM, and 11/28/2024 at 8:45 PM. The progress notes indicated "Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest." The progress notes did not indicate a physician was notified of the severe drug to drug interaction on any of the aforementioned dates. A review of Resident 1's Progress Notes dated 11/28/24 at 8:45 PM, indicated a medication administration order had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL. The progress notes indicated "Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest." The note did not indicate the physician was notified of the severe drug to drug interaction. A review of Resident 1's Medication Administration Record (MAR) for 11/2024, indicated Amiodarone HCL oral tablet a day for A-Fib hold for apical pulse <60 (per pharmacy recommendation) start date 11/29/24. The MAR had a section to document the resident's BP but did not have a section to document the resident's pulse. The MAR indicated administration was as follows: 11/29/2024: Dose held, BP 99/67 mmHg, (per vital sign documentation pulse was 71 bpm [did not indicate if apical] on 11/29/24 at 9:34 am). The pulse did not indicate if checked apically. 11/30/2024: Dose held, BP 99/70 mmHg, pulse not indicated. No pulse documented in medical record for 11/30/24 at 9 am if checked apically as ordered. A review of Resident 1's MAR for 11/2024, indicated to administer Metoprolol Succinate ER oral, one tab one time day (9 AM) for HTN and to hold the medication for SBP <100 mmHg and HR<60 per minute. The MAR further indicated the following about Metoprolol ER: 11/4/2024: Dose held. No documented BP or HR/AP, BP not indicated/documented in Resident 1's chart (no vital signs documented in medical record) 11/7/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record) 11/13/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in Resident 1's chart) 11/19/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record). 11/20/2024: Dose held, BP or pulse not indicated/documented on the MAR or on medical records. 11/24/2024: Dose administered, BP 93/66 mmHg, pulse 66. 11/28/2024: Dose administered, BP 90/60 mmHg, pulse 74. 11/29/2024: Dose administered, BP 99/67 mmHg, pulse 71. The 11/2024 MAR did not indicate a physician was notified for held metoprolol ER and for VS parameters out of prescribed range. A review of Resident 1's MAR for 11/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day (9am) for CHF hold for SBP <100 administration was as follows: 11/4/2024: Dose held; BP not documented on the MAR or on medical records. 11/7/2024: Dose held; BP not documented on the MAR or on medical records. 11/13/2024: Dose held; BP not documented on the MAR or on medical records. 11/15/2024: Dose administered, BP 90/60 mmHg [BP taken at 11:02 am] (parameter indicated hold for SBP <100) 11/17/2024: Dose administered BP 90/60 mmHg. 11/19/2024: Dose held, BP and pulse not documented on the MAR or on medical records. 11/20/2024: Dose held, BP not indicated, pulse not documented (no vital signs documented in medical record) 11/24/2024: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] 11/25/2024: Dose held; BP not indicated on MAR. 11/26/2024: Dose held, BP not indicated, pulse not documented (no vital signs documented in medical record). 11/30/2024: Dose administered, BP 99/70 mmHg. The 11/2024 MAR did not indicate a physician was notified for held Spironolactone Oral tablet 25mg give 0.5mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for 11/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 11/4/2024: Dose held; BP not documented on the MAR or on medical records. 11/7/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/13/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/15/2024: Dose administered, BP 90/60 mmHg [BP taken at 11:02 AM] (parameter indicated hold for SBP <100) 11/17/224: Dose administered BP 90/60 mmHg 11/19/2024: Dose held, BP and pulse not documented on the MAR or on medical records. 11/20/2024: Dose held, BP and pulse not documented on the MAR or on medical records. 11/24/2024: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] 11/25/2024: Dose held; BP not documented on MAR. 11/26/2024: Dose held, BP not documented on the MAR or on medical records. 11/30/2024: Dose administered, BP 99/70 mmHg. The 11/2024 MAR did not indicate a physician was notified for held Entresto 24-26 mg give 0.5 mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for 12/2024, indicated Amiodarone HCL 200mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation) administration was as follows: 12/1/2024: Dose administered, BP 97/65 mmHg, Apical pulse not documented. 12/2/2024: Dose held, BP 98/59 mmHg, Apical pulse not documented. 12/3/2024: Dose held, BP 101/50 mmHg, Apical pulse not documented. 12/4/2024: Dose administered, BP 96/62 mmHg, Apical pulse not documented. 12/5/2024: Dose administered, BP112/76 mmHg, Apical pulse not documented. 12/6/024: Dose administered, BP 104/61 mmHg, Apical pulse not documented. 12/7/2024: Dose administered; Apical pulse not documented. 12/8/2024: Dose held; Apical pulse not documented. 12/9/2024: Dose administered, BP 104/69 mmHg, Apical pulse not documented. The 12/2024 MAR did not indicate a physician was notified for held Amiodarone HCL Oral tablet 200mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for 12/2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60 administration was as follows: 12/1/2024: Dose held, BP and pulse not documented (no vital signs documented in medical record). 12/7/2024: Dose held, BP and pulse not documented on the MAR or on medical records. 12/9/2024: Dose administered, BP 104/69 mmHg, pulse 84. A review of Resident 1's MAR for 12/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day for CHF hold for SBP <100 administration was as follows: 12/1/24: Dose held; no BP documented on the MAR. VS not documented on medical records. 12/7/2024: Dose held; no BP documented. VS not documented in medical records. 12/8/2024: Dose held; no BP documented. VS not documented in medical records. 12/9/2024: administered, BP 104/69 mmHg. A review of Resident 1's MAR for 12/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 12/1/2024: 9 AM: Dose held; BP not documented. 12/7/2024: 9 AM: Dose held; BP not documented. 12/8/2024: 9 AM: Dose held; BP not documented in medical records. A review of Resident 1's MAR for