Other·November 21, 2022

§483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - i. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and ii. Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). 42CFR §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 22 CCR 72355: Pharmaceutical Service--Requirements. (a) Pharmaceutical service shall include, but is not limited to, the following: (1) Obtaining necessary drugs including the availability of 24-hour prescription service on a prompt and timely basis as follows: (D) Refill of prescription drugs shall be available when needed. (2) Dispensing of drugs and biologicals. (3) Monitoring the drug distribution system which includes ordering, dispensing and administering of medication. (4) Provision of consultative and other services furnished by pharmacists which assist in the development, coordination, supervision and review of the pharmaceutical services within the facility. 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. 22 CCR § 72527. Patients' Rights. (b) (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (c) (7) To be encouraged and assisted throughout the period of stay to exercise rights as a patient and as a citizen, and to this end to voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination, or reprisal. On 10/3/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to: 1. Ensure Resident 1, who had diagnosis of seizure disorder (sudden, uncontrolled electrical disturbance in the brain that can cause changes in movements [convulsions] and levels of consciousness [alertness]), received medications including Klonopin (clonazepan - anti seizure medication), Vimpat (lacosamide - antiseizure medication) and Topamax (topiramate - antiseizure medication) between 8/9/2022 and 9/30/2022 , as ordered to meet the resident's needs while Resident 1 was absent (gone for medical appointments) from the facility. 2. The facility did not administer or make arrangements for Resident 1 to receive Klonopin (clonazepan - anti seizure medication), Vimpat (lacosamide - antiseizure medication) and Topamax (topiramate - antiseizure medication) between 8/9/2022 and 9/30/2022, while Resident 1 was absent (gone for medical appointments) from the facility. 3. Develop and implement a comprehensive, individualized plan of care for Resident 1, who had a diagnosis of seizure disorder and had physician's orders for three routine antiseizure medications (Klonopin, Vimpat and Topamax). 4. Develop a plan of care with the participation of the interdisciplinary team (IDT- A group of experts from various disciplines working together to treat a person's ailment, injury, or chronic [long term] health condition) including the attending physician addressing Resident 1's multiple absences (out of the facility for appointments) which interfered with the administration of antiseizure medications. As a result, Resident 1: 1. Missed 17 doses of Topamax, 22 doses of Klonopin, and 12 doses of Vimpat between 8/9/2022 and 9/30/2022. 2. Experienced falls on 9/7/2022 and 10/1/2022 possibly due to seizures, was hospitalized at the General Acute Care Hospital 1 (GACH 1) on 10/1/2022 and was at increased risk for breakthrough seizures due to missing aforementioned antiseizure medications. A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1, on 8/9/2022 with diagnoses including traumatic brain injury (brain dysfunction caused by an outside force), seizures, attention-deficit hyperactivity disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness), history of falling, and depression (a mental health disorder characterized by persistently low mood and loss of interest in daily activities). A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 8/13/2022, indicated the resident was able to communicate, make decisions and remember. 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, dated 8/9/2022, indicated the resident is to receive the following medications: Klonopin 1 milligrams (mg) give one (1) tablet by mouth two times a day for seizures 1mg give two (2) tablets by mouth at bedtime for seizures, Topamax 100 mg give one (1) tablet by mouth four times a day for seizures; and Vimpat 200 mg give (1) tablet by mouth four times a day for seizures. A review of Resident 1's Medication Administration Record (MAR) dated for the month of 8/2022 to 9/30/2022, indicated "11-off unit" and or "9-other/see nurse notes." The MAR further indicated Resident 1 did not receive Vimpat 200 mg 1 tab by mouth on the following dates and times: 8/9/2022 at 5:00 pm, 8/23/22 at 5:00 pm, 8/24/22 at 5:00 pm, 8/25/2022 at 5:00 pm, 8/26/2022 at 9:00 am, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm, 9/14/2022 at 5:00 pm, 9/15/2022 at 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 5:00 pm; and 9/29/2022 at 5:00 pm. A review of Resident 1's MAR dated from 8/9/2022 to 9/30/2022, indicated "11-off unit" and or "9-other/see nurse notes." The MAR further indicated Resident 1 did not receive Topamax 100 mg tablet by mouth on the following dates and times: 8/9/2022 at 5:00 pm, 8/24/2022 at 5:00 pm, 8/25/2022 at 5:00 pm and 9:00 pm, 8/26/2022 at 9:00 am and 1:00 pm, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm and 9:00 pm, 9/13/2022 at 1:00 pm, 9/14/2022 at 1:00 pm and 5:00 pm, 9/15/2022 at 1:00 pm and 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 1:00 pm and 9:00 pm; and 9/29/2022 at 1:00PM and 5:00 pm. A review of Resident 1's MAR, dated 8/9/2022 to 9/30/2022, indicated "11-off unit" and or "9-other/see nurse notes." The MAR further Resident 1 did not receive Klonopin 1mg tablet by mouth on the following dates and times: 8/9/2022 at 5:00 pm, 8/23/2022 at 5:00 pm, 8/24/2022 at 5:00 pm, 8/25/2022 at 5:00 pm and 9:00 pm, 8/26/2022 at 9:00 am, 8/30/2022 at 5:00 pm, 9/8/2022 at 5:00 pm and 9:00 pm, 9/14/2022 at 5:00 pm, 9/15/2022 at 5:00 pm, 9/17/2022 5:00 pm, 9/18/2022 at 9:00 am and 5:00 pm, 9/22/2022 at 5:00 pm, 9/27/2022 at 5:00 pm; and 9/29/2022 at 5:00 pm., 9/30/2022 at 9:00 pm. A review of Resident 1's MAR dated from 8/9/2022 to 9/30/2022, indicated "11-off unit" and or "9-other/see nurse notes." The MAR further indicated Resident 1 did not receive Klonopin 2 mg tablet by mouth on the following dates and times: 8/23/2022 at 9:00 pm, 8/25/2022 at 9:00 pm, 9/8/2022 at 9:00 pm, 9/17/2022 at 9:00 pm, 9/18/2022 at 9:00 pm; and 9/30/2022 at 9:00 pm. A review of Resident 1's Change of Condition (COC) document dated 9/7/2022 timed at 3:35 pm, indicated "the resident stated he lost his balance when he got out of bed, fell, and hit the right side of his ribs on the footboard of his bed. The physician was notified, and no new orders were received." A review of Resident 1's COC dated 9/15/2022 at 10:00 pm, indicated Resident 1 "reported that he fell on the floor in the hallway trying to sit in his wheelchair after he came back from the doctor's (dr) at around" 9:45 pm. Resident 1 "was able to help himself up back to the wheelchair unassisted." A Certified Nurse Assistant (CNA) wheeled Resident 1 to his room. Upon assessment, the charge nurse found "redness and minimal abrasions on" Resident 1's "back." Resident 1 "complained of pain on his right side of his back from previous fall on 9/17/2022. Medical Doctor was notified." A review of Resident 1's plan of care titled "The resident claimed he fell in his room with no injury, poor balance," dated 9/15/2022, indicated the goals included Resident 1 to resume usual activities without further incident through the review date. The interventions included assessing the wheelchair for safety, check Resident 1's range of motion, monitor/document/report to the physician signs and symptoms of pain, bruises (an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels), change in mental statues, new onset of confusion, sleepiness, inability to maintain posture, and agitation. A review of Resident 1's plan of care titled "The resident has seizure disorder r/t (related to) disease process," dated 9/16/2022, indicated the goal included Resident 1 will be free from injury from seizure activity through the review date. The interventions included giving the medications as ordered and monitoring/documenting effectiveness and side effects. A review of Resident 1's plan of care titled " ... warning for use of Clonazepam (Klonopin) indication: seizure," dated 9/16/2022, indicated the goal included Resident 1 will not experience side effects/interactions with the use of Clonazepam (Klonopin). The interventions included to administer medication as ordered, monitor signs (is something found during a physical exam or from a laboratory test that shows that a person may have a condition or disease) and symptoms of adverse effect (An unexpected medical problem that happens during treatment with a drug or other therapy) and notify the physician if Resident 1 experienced signs of adverse effects from Clonazepam A review of Resident 1's COC dated 10/1/2022 at 12:39 pm, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) for evaluation due to "alleged fall incident." A review of GACH 1's History and Physical examination for Resident 1, dated 10/1/2022, indicated the resident presented to the emergency department with neck and back pain after ground level fall. Resident 1 reported falling because he had a seizure while lying in the bed and rolled off the bed. Resident 1 reported a headache, neck, and back pain. Resident 1 reported he had been missing his seizure medications while at the facility. Resident 1 appeared to have a breakthrough seizure (seizures that occur in a person who had previously good consistent control of epilepsy documented in the medical records and then gets another seizure). Resident 1 was instructed to follow up with neurology (branch of medicine dealing with disorders of the nervous system). On 10/3/2022 at 5:20 pm, during an interview, Resident 1 stated he fell three times since his admission to the facility and the falls were related to having seizures because of missing several medications while in the facility. Resident 1 stated he knew when "a seizure is about to happen." Resident 1 stated he fell out of the bed and landed on his back and hit his head on 10/1/2022. Resident 1 stated, he had a brain injury when he was 10 years old and currently was prescribed Topamax, Vimpat, and Klonopin, which have managed his seizures. Resident 1 stated Licensed Vocational Nurses 1, 2, and 3 (LVN 1, LVN 2, and LVN 3) refused to give him his medications when he goes out for doctors' appointments because the medications, "are controlled." Resident 1 stated when he returns to the facility and asks the nurses to give him his medications, the nurses would not administer his medications because the medications were on a timed schedule. Resident 1 stated he discussed on several occasions with the former ADM and with the DON his concerns with the missing medications and the fact that his attending physician had not come to the facility to see him. Resident 1 stated he went for a consult outside the facility and the physician gave him Avoay (migraine medication) which he gave to a nurse (unable to recall the nurses name) to keep in the facility's refrigerator and "they still have not given me that medication." Resident 1 stated he has not seen a physician since admission on 8/9/2022. Resident 1 stated this was the reason he was scheduling and coordinating his own medical care outside of the facility. On 10/4/2022 at 9:17 AM, during an interview, the DON stated the facility was unable to locate requested medication pharmacy delivery receipts for Resident 1. On 10/4/2022 at 11:28 am, during an interview, LVN 1 stated she did not administer Resident 1's seizure medications when he goes out for his appointments." LVN 1 stated, she did not contact or notify Resident 1's physician that the resident had been missing (not administered) his medications. LVN 1 stated the facility did not arrange for Resident 1 to receive/continue taking his antiseizure medications when he goes out. On 10/4/2022 at 3:06 pm, during an interview with the DON and concurrent review of Resident 1's MAR dated from 8/22 to 9/30/2022, the DON stated she was not aware Resident 1 was not receiving antiseizure medications. The DON acknowledged Resident 1 had missed multiple doses of Topamax, Vimpat, and Klonopin medications. The DON stated missing so many doses could result in Resident 1 having seizures and did not follow up with Resident 1's physician. On 10/4/2022 at 3:37 pm, during an interview, LVN 2 stated Resident 1's physician had not visited the resident since admission and the Medical Records Department was responsible to contact the residents' medical doctors whenever they did not come to the facility to visit their residents. LVN 2 stated she did not call Resident 1's physician to come and evaluate Resident 1 and about the missed doses of anti-seizure medications. LVN 2 stated missing anti-seizure medications could result in seizures. On 10/4/2022 at 5:35 pm, during an interview, LVN 3 stated she did not notify the attending physician or the DON about Resident 1's missed antiseizure medications when he was absent from the facility. LVN 3 stated there was no care plan developed to address the residents' multiple absences from the facility and how to proceed with the medications scheduled when Resident 1 was out. On 10/6/2022 at 11:03 pm, during an interview, the DON stated the LVNs did not communicate to her that Resident 1 had been missing his antiseizure medications. The DON stated, "the nurses must notify the medical doctor for any medications that the resident (Resident 1) will be missing, and this did not happen." The DON acknowledged the licensed nurses failed to develop a care plan to ensure Resident 1 did not miss his antiseizure medications whenever Resident 1 was away from the facility. The DON stated she did not inform the physician that Resident