Health inspection·October 30, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00924018. State Citation (WMF) was written. 1424 (f) (1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2) "Willful material falsification," as used in this section, means any entry in the patient 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 decubitus 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 10/08/2024, an unannounced visit was conducted at the facility to investigate an abbreviated survey regarding falsification of resident records. The facility staff willfully falsified Resident 1's medical records by documenting that the medications cinacalcet (medication to treat patients with chronic [ongoing] kidney disease who are on dialysis), sevelamer (medication binds phosphorus [mineral] from foods in the diet and prevents phosphorous from being absorbed into the blood stream), and lanthanum carbonate (medication used to treat hyperphosphatemia [high level of phosphorous [phosphate, a mineral found in bones, teeth, muscles, nerves, and blood]) were administered to the resident on 10/04/2024 at 12:05 PM. The Licensed Vocational Nurse 3 (LVN 3) documented that LVN 3 administered the medications to Resident 1, but Resident 1 was not in the facility. Based on the facility's surveillance video footage dated 10/04/2024 at 9:30 AM, Resident 1 left the facility at 9:36 AM and did not return to the facility. LVN 3 falsified Resident 1's medical records for that day by documenting in Licensed Nurses Notes that LVN 3 administered medications to Resident 1 at 12:05 PM, LVN 3 saw Resident 1 in resident's room at 1:30 PM, that LVN 3 saw Resident 1 sitting on the couch at 2:15 PM, and LVN 3 saw Resident 1 in the dining room at 3 PM. As a result, the facility documented medications administration inaccurately in Resident 1's Medical Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications given to a resident) and Resident 1 Licensed Nurses Notes. A review of Resident 1's history and physical (H&P - a physician's complete patient examination) dated 12/06/2023 indicated that Resident 1 had the capacity for medical decision making. A review of Resident 1's face sheet (Admission Record- a document containing demographic and diagnostic information) indicated Resident 1 was admitted to the facility on 8/17/2024 with the following diagnoses: metabolic encephalopathy (brain dysfunction caused by an underlying condition), end stage renal disease (ESRD- when the kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), and iron deficiency anemia (a condition when the body does not have enough iron to produce healthy red blood cells). A review of Resident 1's care plan titled Elopement dated 8/18/2024 indicated Resident 1 was at risk for elopement related to a history of leaving AMA (against medical advice - when a patient leaves a facility against the advice of the doctor) prior to admission to the facility. The care plan indicated the goal for Resident 1 would be remain safe in the facility daily for 90 days. The care plan interventions indicated Resident 1 would be assessed for risks for elopement, elopement history and patterns would be obtained from family, scenarios that may trigger elopement would be evaluated, and Resident 1 would be placed in an area where the resident can be easily supervised by staff. During a review of Resident 1's Minimum Data Set, (MDS a federally mandated resident assessment tool) dated 8/23/2024, the MDS indicated Resident 1 was cognitively intact (mental ability to make decisions on activities of daily living), was able to walk without any device assistance/device and had no behavioral symptoms (represents the complaints of the patient). During a review of the Licensed Nurses Notes dated 10/04/2024 at 7 AM, indicated, LVN 3 documented that Resident 1 was alert and oriented and was seen by LVN 3 sitting on the couch in the lobby/reception area. During a review of the Licensed Nurses Notes dated 10/04/2024 at 9:30 AM, indicated, LVN 3 documented: "regular meds routinely given as ordered, Vital signs (VS) taken Blood Pressure (BP) 133/82, Temperature (t) 98.2, Pulse (P) 76, Respiratory (R) 18, Oxygen saturation (O2 Sat) 98, No signs of distress." During a review of the Licensed Nurses Notes dated 10/04/2024 at 12:05 PM, indicated, LVN 3 documented "noon meds given as ordered, Noted Resident ambulating to the dining room for lunch." During a review of the Licensed Nurses Notes dated 10/04/2024 at 1:30 PM, indicated, LVN 3 documented "Resident noted seated in his room." During a review of the Licensed Nurses Notes dated 10/04/2024 at 2:15 PM, indicated, LVN 3 documented "resident ambulation to the living room and sit at the lobby sofa." During a review of the Licensed Nurses Notes dated 10/04/2024 at 3 PM, indicated, LVN 3 documented "resident in the dining room, oriented, no distress." A review of Physician Orders for the month of 10/2024 indicated Resident 1 was on the following medications: 1. Cinacalcet 90 milligrams (mg, unit of measurement) PO (by mouth) after lunch diagnosis (DX) ERSD. 2. Sevelamer oral powder give 0.8 GMS give 3 packets of 24 grams (GMS, unit of measurement) PO three times a day (TID) mix each packet with 30 ml water. Administer within 30 minutes at beginning of each meal for hyperphosphatemia. 3. Lanthanum Carbonate 1000 mg chew tab 1 PO TID at middle of meals DX high phosphorous. During a review of Resident 1's MAR for 10/2024, the MAR indicated LVN 3 initialed/documented that on 10/04/2024, LVN 3 administered the following medications/supplements to Resident 1: 1. Cinacalcet 90 mg PO administered at 12:30 PM. 2. Sevelamer oral powder give 0.8 GMS give 3 packets administered at12 PM. 3. Lanthanum Carbonate 1000 mg administered at 12 PM. During a telephone interview on 10/08/2024 at 10:02 AM with Resident 1's family member 1 (FM 1), FM 1 stated Resident 1 arrived at the FM 1's residence "on 10/04/2024 at around 10 AM or 11 AM, [Resident 1] came alone." FM 1 stated FM 1 did not expect Resident 1 to show up at FM 1's residence. FM 1 stated Resident 1 told FM 1 that resident left the facility because the resident did not like the breakfast served at the facility. FM 1 stated the facility did not notify FM 1 that Resident 1 was missing from the facility. FM 1 stated FM 1 contacted the facility and informed Receptionist 2 (R2) that Resident 1 was with FM 1. FM 1 stated Resident 1 was with FM 1 and family since the resident's arrival on 10/04/2024. During an interview with Certified Nurse Assistant 1 (CNA 1) on 10/08/2024 at 2:11 PM, CNA 1 stated Resident 1 usually walks around in circles in the facility, in the dining room, and in the patio. CNA 1 stated Resident 1 would be sitting on the couch "whenever I come to work, I will find [Resident 1] there [couch] a lot, just sitting, nothing else." During an interview with LVN 3 on 10/08/2024 at 2:30 PM, LVN 3 stated LVN 3 made resident rounds (check on residents to ensure their safety and well-being) four times during the 7 AM to 3 PM shift on 10/04/24. LVN 3 stated after LVN 3 completed the resident rounds, LVN 3 only documented if there was a change of condition (COC- communication between members of the health care team and used as a tool to foster patient safety) on any of the residents. LVN 3 stated that on most days, LVN 3 was responsible/assigned to provide care to Resident 1. LVN 3 stated LVN 3 saw Resident 1 sitting on the couch in the facility's front lobby "not doing anything" time/date not specified. LVN 3 stated the facility trained LVN 3 on elopement and wandering within the last 12 months. During an interview with Registered Nurse 1 (RN 1) on 10/08/2024 at 3:25 PM, RN 1 stated documentation on the residents' locations was done only when the resident/s developed any changes of condition. RN 1 stated Resident 1, "wanders around from one place to another...activity room, lobby/reception, dining room, patio/smoking areas. Looks like [Resident 1] is always in deep thoughts; like...thinking all the time." RN 1 stated Resident 1 left the facility against medical advice (AMA - when a patient leaves a facility against the advice of the doctor) sometime in 8/2024." During a concurrent observation, interview, and record review on 10/09/2024 at 12:38 PM with Administrator (ADM) and Payroll Assistant (PA), the facility's surveillance video footage dated 10/04/2024 was reviewed. When asked if ADM had seen the video footage where Resident 1 was seen leaving the facility, the ADM stated "I did, but it's not...it's...I was just scrolling and maybe I was going too fast. I didn't see [Resident 1] in any of the videos." The facility's surveillance video footage dated 10/04/2024 was reviewed. The video footage dated 10/04/2024 at 8:38 AM, indicated Resident 1 was standing in the lobby area and was looking at the facility's front door. The PA stated, "looks like he [Resident 1] is getting ready to leave" and ADM also stated, "yeah, [Resident 1] is." The video footage indicated that on 10/04/2024 at 9:36 AM, there was no staff in the lobby/reception area and that Resident 1 left the facility through the facility's front door. During a concurrent interview and record review with Receptionist 1 (R1) on 10/09/2024 at 3:02 PM, the facility's surveillance video footage dated 10/04/2024 was reviewed. The facility surveillance video footage indicated the following: 1. On 10/04/2024 at 9:34 AM, R1 left the reception desk, no person/staff at the desk/front lobby when R1 left the reception desk. 2. On 10/04/2024 at 9:36 AM, Resident 1 left the facility through the front door. 3. On 10/04/2024 at 9:38 AM, R1 returned to the front desk. There were no person/staff at the desk/front lobby during R1's absence. During a concurrent interview, and record review on 10/09/2024 at 3:32 PM with LVN 3, the facility's surveillance video footage dated 10/4/2024 was reviewed. LVN 3 reviewed the surveillance video footage where Resident 1 was seen leaving the facility on 10/4/2024 at 9:36 AM through the front door. LVN 3 was observed shaking her right leg, straightened her back and observed her eyes widened. LVN 3 stated "I saw the patient [Resident 1] the entire shift on 10/04/2024, like the hours I told you (referring to the Licensed Nurses Notes document dated 10/04/2024)" and "that video....that one (pointing to the video screen), I...I don't know. All I know is that I saw the patient on each hour that I wrote on the document [Licensed Nurses Notes dated 10/04/2024]." When LVN 3 was asked why LVN 3 documented on the Licensed Nurses Notes dated 10/04/2024 that LVN 3 saw Resident 1 on 10/04/2024 at 12:05 PM, 1:30 PM, 2:15 PM, and 3 PM despite the surveillance video footage indicating that Resident 1 already left the facility on 10/04/2024 at 9:36 AM, LVN 3 stated, "because I gave the medicine that morning at the time I wrote it, he was here; for all I know, I saw [Resident 1]. I cannot tell anymore because I saw [Resident 1] at 2:15 pm and at 3pm. That's the last time I saw him, at 3pm. That's it." LVN 3 stated that LVN 1 told LVN 3 that Social Service Director (SSD) and Social Service Assistant (SSA) saw Resident 1 sitting on the couch in the lobby/reception area on 10/04/2024 approximately 2:15 PM. When LVN 3 was asked why LVN 1 would tell LVN 3 that information, LVN 3 stated "I don't know." During a concurrent interview and record review on 10/09/2024 at 5:27 PM with the Director of Nursing (DON) and ADM, the facility's surveillance video footage dated 10/04/2024 was reviewed. The ADM confirmed that it was Resident 1 on the video leaving the facility on 10/04/2024 at 9:36 AM. During a review of the facility's policy and procedures (P&P) titled "Routine Resident Checks" reviewed date on 07/12/2024, indicated, "nurses shall keep documentation related to routine checks that included time, identity of the person making the checks, and any outcomes of each check." During a review of the facility's policy and procedures (P&P) titled "Medication Administration Preparation and Guidelines" revised on 07/14/2024, indicated, "Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so... b. Medications are administered in accordance with written orders of the attending physician... f. Residents are identified before medication is administered. Methods of identification include: 1. Checking identification band 2. Checking photograph attached to medical record. 3. Calling resident by name 4. If necessary, verifying resident identification with other facility personnel... m. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR is flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication. 3. Documentation a. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report to off-duty without first recording the administration of any medications... d. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are verified with a full signature in the space provided. 4. Signature or initials of persons recording administration and signature of initials of person recording effects, if different from the person administering the medication. During a review of the facility's P&P titled "Charting and Documentation" revised on 07/14/2024, indicated, "It is the policy of the facility to document all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, in the resident's medical record. The medical record, electronic or otherwise, should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation: 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record: a. Objective observations. b. Medications administered. c. Treatments or services performed. d. Changes in the resident's condition. e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives... 7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care. c. The assessment data and/or any unusual findings obtained during the procedure/treatment. d. How the resident tolerated the procedure/treatment. e. Whether the resident refused the procedure/treatment. f. Notification of family, physician, or other staff, if indicated; and g. The signature and title of the individual documenting. The facility staff failed to ensure entry in Resident 1's medical records were not falsified by documenting that the medications cinacalcet, sevelamer, and lanthanum carbonate were administered to the resident on 10/04/2024 at 12 PM and12:30 PM. Resident 1's medications were not administered on scheduled per phys