Health inspection·April 11, 2025

F760 The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. 22 CCR § 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: (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. 22 CCR §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 2/24/2025 the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to ensure Residents 37 and 66 received care and services in accordance with professional standards of practice and were free of significant medication error. The facility failed to: -Ensure Resident 37 was administered Keppra (levetiracetam, a medication used to control seizures) on 2/20, 2/22, 2/23, 2/24, and 2/25/2025 at 9 AM and 5 PM daily as ordered. -Ensure Resident 66 was administered medications in accordance with physician's orders, facility's policy and procedures (P&P) titled, "Medication Administration - General Guidelines" to minimize the risk of adverse consequences which could lead to a deterioration in the resident's condition, hospitalization, harm, or death, and failed to rotate the administration sites of insulin (a hormone that helps regulate blood sugar levels by moving glucose from the blood into the cells). As a result Resident 37, a 74 year old female, was placed at high risk for hepatotoxicity (liver toxicity, a condition that occurs when the liver is damaged by harmful substances, such as medications, toxins, or chemicals, which can lead to impaired liver function and, in severe cases, liver failure) and Resident 66, a 76 year old female, was placed at risk for uncontrolled blood glucose (sugar) levels. a.A review of Resident 37's Admission Record indicated the resident was admitted to the facility on 12/12/2018 and readmitted 3/25/2021 with diagnoses including seizures and traumatic subdural hemorrhage (a brain injury that occurs when blood builds up between the brain and the skull) with loss of consciousness of unspecified duration A review of Resident 37's Minimum Data Set (MDS, a resident assessment tool) dated 12/18/2024, indicated the resident's cognitive skills for daily decision-making was moderately impaired (problems with thinking, reasoning and remembering), required set up for eating, and was dependent on staff for physical assistance with oral hygiene, bathing, and dressing. A review of Resident 37's History and Physical (H&P) dated 3/31/22, indicated the resident can make needs known but cannot make medical decisions. A review of the Physician's Order Summary Report for February 2025 indicated Resident 37 had an order for Keppra (levetiracetam) 500 milligrams (mg, unit of measurement) to give one tablet by mouth two times a day, scheduled at 9 a.m. and 5 p.m., for seizures. A review of Resident 37's Care Plan revised 2/7/2025 indicated the resident had a seizure disorder and the interventions were to give seizure medication as ordered by doctor, to monitor and document side effects and effectiveness. A review of Resident 37's Medication Administration Audit Report for 2/17 to 2/26/2025 indicated the following: -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 2:12 p.m., on 2/20/2025, which was five hours and 12 minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:47 p.m. on 2/20/2025, which was three hours 35 minutes after the last dose was given at 2:12 p.m. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:01 a.m., on 2/22/2025, two hours later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:24 a.m., on 2/23/2025, two hours and 24 minutes later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:11 p.m., on 2/24/2025, over three hours later than scheduled. -Resident 37's scheduled 5 p.m. dose of levetiracetam was given at 10:54 p.m., on 2/24/2025, almost six hours later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:06 p.m., on 2/25/2025, which was three hours and six minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:29 p.m. on 2/20/2025, which was four hours 23 minutes after the last dose was given at 12:06 p.m. During an interview on 2/26/2025 at 1:37 p.m., the facility's Pharmacy Consultant (PC) stated the facility was supposed to have a process in place to have another nurse help to ensure medication administration did not run into the noon or next medication administration time if residents had medications scheduled for two or three times a day. The PC stated he suggested to the facility's Assistant Director of Nursing (ADON) and the Director of Nursing (DON) several months ago, having another nurse to assist with medication pass to prevent late medication administration. The PC stated when medications were administered over three hours late, that was not acceptable practice. The PC stated it was important to give apixaban as ordered because of the pharmacokinetics (the movement of drug into, though, and out of the body) of the medication to maintain therapeutic effects (the response(s) after a treatment of any kind, the results of which were judged to be useful or favorable). The PC stated giving anticoagulants, such as apixaban too close together may increase the risk of bleeding, toxicity (the degree to which a substance can harm an organ), and the licensed nurses must monitor residents on anticoagulants for bleeding. The PC stated administering BP medications too close to the next dose could result in the resident's BP dropping, the nurse must check the resident's BP before administering the next dose. The PC stated residents on once-a-day BP medication may not have good blood pressure control when BP medications were given later than ordered or not administered about the same time each day. The PC stated the facility nurses should notify the physician of a late or missed dose right away. During an interview on 2/26/2025 at 2:05 p.m., the facility's Medical Director (MD) 1 stated residents must be administered their medications as consistently and in a timely manner as ordered by the physician. MD 1 stated if residents were not administered medications as close to the scheduled administration time as possible residents being medicated for seizures, high blood pressure, diabetes, or on anticoagulants may have loss of control of seizures, blood pressure, diabetes, or be at risk for bleeding. MD 1 stated not administering the residents' medication as ordered could lead to deterioration in the resident's condition for any of the conditions that the prescriber was treating the resident for. MD 1 stated administering resident's medication as close to the scheduled administration time helped to prevent a deterioration in the resident's condition. A review of the facility's P&P titled, "Medication Administration - General Guidelines," dated 10/2012 (currently policy), indicated Medications were administered as prescribed in accordance with good nursing principles and practices. The facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) were compared with the medication label, if there was any other reason to question the dosage or directions, the physician's orders were checked for the correct dosage schedule. Medications were administered within 60 minutes of scheduled time, except before, with or after meal orders, which were administered based on mealtimes. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication was given. The P&P indicated if a dose of regularly scheduled medication was withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration was initialed and circled. An explanatory note was entered on the reverse side of the record, the physician was notified. Nursing documents the notification and physician's response. If an electronic MAR system was used, the specific procedures required for identifying medications due at specific times, and documentation of administration were described in the system's user manual. These procedures should be followed. b. A review of Resident 66's Admission Record indicated the resident was admitted to the facility on 4/14/2023 with diagnoses including Type II diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being). A review of the Physician' Orders dated 1/23/2024, indicated Resident 66 was to receive Lispro Insulin (a medication used to manage diabetes by lowering blood sugar levels) per sliding scale (a chart with preestablished insulin doses used to determine the dose to be administered to an individual based on blood sugar levels) subcutaneously (a method of administering medication by injecting it into the fatty layer of tissue just beneath the skin) before meals and at bedtime for DM. A review of Resident 66's MDS dated 1/3/2025 indicated the resident had moderate cognitive impairment and was receiving a hypoglycemic medication (medication used to lower blood sugar levels). A review of Resident 66's MAR dated 2/1 - 2/28/2025 indicated the resident received insulin in the left arm on 2/10/2025 at 5:34 AM, 4:30 PM, and 8:49 PM. The MAR indicated the resident received insulin in the left lower quadrant of the abdomen on 2/14/2025 at 5:28 PM, and 8:50 PM. During a concurrent interview and record review on 2/25/2025 at 11:13 AM, Resident 66's MAR dated 2/1 - 2/28/2025 was reviewed with Registered Nurse (RN) 2. RN 2 confirmed that Resident 66 did not have her administration sites rotated when insulin was administered on 2/10/2025 and 2/14/2025. RN 2 stated administration sites should be rotated to prevent infection. During an interview on 2/25/2025 at 3:06 PM, the DON provided a list of 23 residents which included Residents 8, 10, 11, 32, 54, 66, 95, 99. Eleven of the 23 residents were on Station 2, MedCart 2 and 12 of the 23 residents were on Station 2, MedCart 3, that were administered morning medications scheduled for 9 a.m., over 60 minutes pass the scheduled administration time, close to the next scheduled dose, and/ or not in accordance with the physician's orders between 2/17/2025 - 2/25/2025. The DON stated there was no documentation that the physician was called prior to LVN 1 and LVN 2 administering medications late to residents on Station 2 MedCart 2, nor to residents on Station 2 MedCart 3 on 2/25/2025. The DON stated the physician should have been called before administering medications late to residents and they were working to notify the physicians now. During an interview on 2/27/2025 at 11:19 AM, the DON stated staff should rotate the administration sites of insulin when the insulin was administered to the resident. The DON stated there was a potential for Resident 66 to develop fatty lumps under the skin when insulin administration sites are not rotated. A review of the facility's P&P titled, "Insulin Administration," effective 2/2024, indicated injection sites should be rotated to reduce the risk of damaging skin tissue. The facility failed to ensure Residents 37 and 66 received care and services in accordance with professional standards of practice and were free of significant medication error. The facility failed to: -Ensure Resident 37 was administered Keppra on 2/20, 2/22, 2/23, 2/24, and 2/25/2025 at 9 AM and 5 PM daily as ordered. -Ensure Resident 66 was administered medications in accordance with physician's orders, facility's P&P titled, "Medication Administration - General Guidelines" to minimize the risk of adverse consequences which could lead to a deterioration in the resident's condition, hospitalization, harm, or death, and failed to rotate the administration sites of insulin. As a result, Resident 37 was placed at high risk for hepatotoxicity and Resident 66 was placed at risk for uncontrolled blood glucose levels. The above violation had direct or immediate relationship to the health, safety, or security of Resident Residents 37 and 66.