Health inspection·October 29, 2024

The following reflects the findings of the California Department of Public Health during a complaint investigation. Complaint number: CA00919321. A WMF Citation was issued. Regulatory Violation. California Health & Safety Code §1424(f) (1) Any willful material falsification or willful material omission in the health record of a resident of a long-term health care facility is a violation. (2) "Willful material falsification," as used in this section, means any entry in the resident's health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of pressure ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the resident or the care or services provided. On 9/19/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate an anonymous complaint regarding quality of care and treatment. On 9/19/2024, LVN (Licensed Vocational Nurse) 1, acting as an employee and agent of the facility, knowingly and willfully falsified the medical records of Resident 3 when she documented that she administered Resident 3's medications on time per the physician's order when no such administration of medications occurred. The facility failed to ensure Resident 3's medical records were not falsified by staff when LVN 1 documented that she administered Resident 3's medications on time per the physician's order when no such administration of medications occurred. As a result, the facility documented medications administration inaccurately in Resident 3's Medical Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications given to a resident). During the unannounced visit to the facility, it was determined that the medical record falsely reflected the care and services provided to Resident 3. A review of Resident 3's Admission Record indicated the facility originally admitted the resident on 11/10/2023 and readmitted on 8/28/2024 with diagnoses including hypertension (HTN - elevated blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide). A review of Resident 3's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 9/3/2024, indicated Resident 3's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired for daily decision-making and required maximal assistance from staff for activities of daily living (ADL- toileting hygiene, shower/bathing and lower body dressing). A review of Resident 3's Physician's Order, dated 8/28/2024, included the following medications: i. Lisinopril (medication used to treat high blood pressure and heart failure) 40 milligrams (mg - unit of measurement), one tablet daily at 9 a.m. ii. Methimazole (medication used to treat excess thyroid hormone) 5 mg, one tablet by mouth three times daily at 9 a.m., 1 p.m. and 5 p.m. iii. Nifedipine (medication used to lowers blood pressure by relaxing the blood vessels so the heart does not have to pump as hard) 60 mg, one tablet by mouth in the morning at 9 a.m. iv. Folic acid (medication used to treat or prevent folate deficiency anemia [low blood count]) 1 mg, one tablet by mouth daily at 9 a.m. A review of Resident 3's Care Plan for risk for exacerbation of elevated blood pressure (BP) due to HTN, dated 8/29/2024 indicated interventions including medications as ordered: lisinopril and nifedipine, BP as ordered and notify medical doctor (MD) if out of range. During a medication pass administration observation with Licensed Vocational Nurse 1 (LVN 1) on 9/19/2024 at 12:15 p.m., observed LVN 1 administered the following medications: lisinopril, methimazole, nifedipine and folic acid to Resident 3. After administering the medications, LVN 1 then signed the MAR under 9 a.m. schedule. When asked if she administered the medications as scheduled, LVN 1 stated, "no". LVN 1 stated, Resident 3 was getting physical therapy in the morning, and she was unable to administer the medications on time. LVN 1 further stated, Resident 3's BP was elevated at 174/84 (normal blood pressure is 120/80 or lower) prior to administering his BP medications. During an interview with Certified Occupational Therapist Assistant 1 (COTA 1) on 9/20/2024 at 9:58 a.m., COTA 1 stated, Resident 3 had his only physical therapy (PT) exercise session of the day on 9/19/2024 after lunch around 1 p.m. During an interview with Director of Rehabilitation Department (DOR) on 9/20/2024 at 10 a.m., DOR stated and confirmed, Resident 3 had only one PT exercise on 9/19/2024, which took place after lunch. The DOR further confirmed she saw Resident 3 walking in the hallway with COTA 1 in the afternoon. During an interview and record review of Resident 3's MAR and Progress Notes (Nurse's notes) as of 9/20/2024 with Registered Nurse 1 (RN 1) on 9/20/2024 at 12:30 p.m., RN 1 stated that medications should be administered as scheduled and per physician's order. RN 1 stated, Resident 3's BP of 174/84 indicated an elevated BP and medications for HTN should be administered on time because it helps maintain their BP at a normal range. RN 1 further stated, if medications were administered late, the clinical nurse should explain in the MAR the reasons, and to also notify the physician. RN 1 further stated, there should also be a monitoring of Resident 3's BP to ensure if the medications were effective. RN1 further stated that Resident 3's medications were administered late, and that the MAR entry indicating timely administration of Resident 3's medications was not accurate. Review of the record indicated there were no notes if monitoring was done when LVN 1 administered Resident 3's medications late on 9/19/2024. There were no notes as well if LVN 1 notified MD regarding Resident 3's elevated BP. RN 1 stated, this was not a safe standard of practice for Resident 3. The medications given late were: lisinopril, methimazole, nifedipine, and folic acid. Resident 3 did not receive these medications at 9am, and methimazole was not given. RN 1 confirmed and stated Resident 3 had an elevated BP of 174/84, taken at 12:08 p.m. prior to administering BP meds (lisinopril and nifedipine). A review of the facility's policy and procedure (P&P) titled, "Medication Administration", reviewed on 7/14/2023 indicated, "Medications are administered in accordance with written orders of the attending physician... Medications are administered within 60 minutes of scheduled time, except before or after meal orders." A review of the facility's P&P titled, "Charting and Documentation", reviewed on 7/12/2024 indicated, "The following information is to be documented in the resident medical record... medications administered... Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate." The facility failed to ensure Resident 3's medical records were not falsified by staff when LVN 1 documented that she administered Resident 3's medications on time per the physician's order when no such administration of medications occurred. As a result, the facility documented medications administration inaccurately in Resident 3's MAR. The above facts indicate that there was a willful material falsification in the medical records for Resident 3.