Health inspection·November 17, 2022

On 10/18/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint related to quality of care The facility failed to ensure Resident 1 was free from significant medication errors when Resident 1 missed the administration of medications to treat hypertension (elevated blood pressure) as ordered by the physician and as per facility's policy. Between 10/1/2022 and 10/18/2022 Resident 1 four doses of Procardia, three doses of Micardis and one dose of Lopressor As a result, Resident 1 was placed at increased risk for complications related to uncontrolled hypertension such stroke (a result of inadequate blood flow to the brain), heart attack (a part of the heart muscle not getting enough blood), and death. A review of Resident 1's Admission Record indicated the facility admitted the resident on 8/9/2022 with diagnoses including attention-deficit hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness), seizures (a sudden, uncontrolled electrical disturbance in the brain), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), muscle wasting and atrophy (wasting or thinning of muscle mass), muscle weakness, insomnia (inability to sleep), history of falling, traumatic brain injury (brain dysfunction caused by an outside force), and hypertension (elevated blood pressure). A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care-screening tool) dated 8/13/2022, indicated Resident 1 was cognitively (mental ability to make decisions of daily living) intact. The MDS indicated Resident 1 required supervision with one-person physical assist for bed mobility, transfers, dressing, toilet use and personal hygiene. A review of the Physician's Orders for Resident 1 indicated the following medications: 1. Micardis 20 milligrams (mg) give 1 tablet by mouth one time a day for hypertension; hold if the systolic blood pressure (SBP- the upper number of BP reading) was less than 110 millimeters of mercury (mmHg) and the heart rate was less than 60 beats per minute (bpm) ordered on 8/9/2022. 2. Lopressor 50 mg give 25 mg by mouth two times a day for hypertension; hold if the SBP less than 110 mmHg and heartrate less than 60 bpm ordered 8/16/2022; and 3. Procardia XL 60 mg give 1 tablet by mouth in the evening for hypertension; hold if the SBP was less than 110 mmHg and heart rate less than 60 bpm ordered on 10/6/2022. A review of Resident 1's Medication Administration Record (MAR) from 10/1/2022 to 10/18/2022, indicated the resident did not receive: - Micardis on 10/4/2022, 10/5/2022, and 10/15/2022. - Lopressor on 10/5/2022 at 5:00 pm. - Procardia on 10/4/2022, 10/5/2022, 10/13/2022, and 10/14/2022. On 10/18/2022 at 12:00 pm during an interview, Resident 1 stated he did not receive his BP medications as ordered by the physician. On 10/18/ 2022 at 3:30 pm, during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that on 10/15/2022, she did not administer Micardis because she could not find the medication in the medication cart. LVN 2 stated she did not call the pharmacy or notify Resident 1's physician. LVN 2 also stated on 10/13/2022 and 10/14/2022, she could not find Procardia and Resident 1 could not get the medications as ordered. LVN 2 stated she did not notify the pharmacy or the resident's physician that Procardia and Micardis ran out. LVN 2 stated the pharmacy only send seven-day supply of the medications. On 10/18/2022 at 3:35 pm, during an interview, the Director of Nursing (DON) stated she would contact the pharmacy consultant and try to resolve the issue of blood pressure medication not delivered in sufficient supply. On 10/19/2022 at 2:52 PM, during an interview, LVN 1 stated she did not give Micardis to Resident 1 on 10/4/2022 and 10/5/2022 because it was not available. LVN 1 contacted the pharmacy but not the physician about the missed doses. On 10/19/2022 at 2:05 pm, during a telephone interview, the Pharmacy Consultant (PC) stated she reviewed medications for Resident 1 for the month of 10/2022 and identified missed doses and charting gaps in the MAR. The PC stated missing BP medication could place Resident 1 at "increased hypertensive reaction." A review of the facility's policy and procedures titled, "Medication Administration-General Guidelines" dated 4/2008, indicated medications are administered as prescribed ... Medications are administered in accordance with written orders of the attending physician. If a dose of regularly scheduled medication is withheld, refused, or given at other than the schedules time (e.g., the resident is not in the facility at scheduled dose time), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. A review of the facility's policy and procedures titled, "Medication Ordering and Receiving from Pharmacy" dated 4/2008, indicated if not automatically refilled by the pharmacy ... Reorder medication five days in advance of need to assure adequate supply is on hand. A review of the facility's policy and procedures titled, "Medication Errors" dated November 2017, indicated It is the policy of this facility that medication errors will be reported to the resident, his/her physician and to the resident/resident representative. A medication error is defined as administration to a resident: ... Omission if prescribed medication (Unless refused by the resident). When first discovered, the medication error shall immediately be reported to the physician for appropriate actions to be taken. The facility failed to ensure Resident 1 was free from significant medication errors when Resident 1 missed the administration of medications to treat hypertension as ordered by the physician and as per facility's policy. Between 10/1/2022 and 10/18/2022 Resident 1 four doses of Procardia, three doses of Micardis and one dose of Lopressor As a result, Resident 1 was placed at increased risk for complications related to uncontrolled hypertension such stroke, heart attack, and death. The above violations had a direct relationship to the health, safety, or security of Residents 1.