Health inspection·November 30, 2023

42 CFR §483.45(f) Medication Errors. The facility must ensure that its— §483.45(f)(1) Medication error rates are not 5 percent or greater; and The facility must ensure that its— 42 CFR §483.45(f)(2) Residents are free of any significant medication errors. On 10/16/2023, 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 its medication error rate was less than 5% and that it was free from significant medication errors affecting Residents 22, 43, and 68. Licensed Vocational Nurses (LVNs) 1, 2, and 3 made 11 medication errors out of 26 total opportunities which contributed to an overall medication error rate of 42.3%. The facility failed to: 1. Ensure that for Resident 22, LVN 1 did not mix three medications for administration through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow) and followed the facility's policy and procedure (P&P) on Medication Pass to give medications one at a time. LVN 1 mixed Keppra and Dilantin, both used for prevention and control of seizures (sudden, uncontrolled burst of electrical activity in the brain), and potassium chloride [KCl, medicine used to prevent or treat low potassium levels in the body; potassium is a mineral the body needs for proper functioning of several organs including the heart). 2. Ensure that for Resident 43, LVN 2 flushed the GT with 50 milliliters (ml, unit of measurement) of water before administering medications, flushed with 5 to 10 ml of water after each of the five medications administered including Xarelto (rivaroxaban, a blood thinner used to treat and prevent blood clots) as ordered by the physician and in accordance with the facility's P&P on Medication Pass via GT, and that LVN 2 allowed the medications to go through the GT by gravity as per P&P. 3. Ensure LVN 3 administered Resident 68 the complete dose of three of six crushed medications via GT including the anticholinergic medication (inhibits saliva production and respiratory secretions) Robinul (glycopyrrolate) and did not leave significant residues of undissolved medications in the medication cup (plastic translucent cup suitable for dispensing both liquid and dry medications, calibrated from 2.5 to 30 ml) in accordance with the physician's orders. As a result, Resident 22 was placed at high risk for increased seizure frequency, duration, or intensity, irregular heartbeats, and to experience adverse drug interactions; Resident 43's was placed on GT complications such as tube blockage, and to experience adverse drug interactions, and aspiration pneumonia (swelling and infection of the lungs or large airways that occurs when food or liquid is breathed into the airways or lungs) and pulmonary embolism (a life-threatening blood clot in the lungs); and Resident 68 was placed at increased risk of developing shortness of breath and airway obstruction. 1. A review of Resident 22's Admission Record indicated the facility admitted the resident on 11/6/2008 with a readmission date of 5/23/2014. Resident 22's diagnoses included seizure disorder, and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide [waste gas made in the body's cells]). Other diagnoses were dependence on respirator (or ventilator, a machine that helps persons that cannot breathe on their own), tracheostomy (a medical procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and GT. A review of Resident 22's History and Physical (H&P) exam, dated 5/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 8/29/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks such as eating, walking, dressing, bathing, moving in bed, toilet use, and personal hygiene). A review of the Physician's Orders for Resident 22 indicated the following medications: - Keppra (antiseizure medication) 1,500 mg via GT every 12 hours for seizure disorder ordered on 7/22/2018. - Dilantin (antiseizure medication) 250 mg via GT every 12 hours for seizure disorder, hold GT feeding one hour before and after medication administration, ordered on 10/4/2023. - Potassium chloride (KCl, medicine used to prevent or treat low potassium levels in the body; potassium is a mineral the body needs for proper functioning of several organs including the heart) 20 milliequivalent (mEq - a unit of measurement) 15 ml via GT, dilute with 200 ml water, give daily as supplement, ordered on 7/5/2023. A review of Resident 22's Care Plan, developed on 5/15/2023 and last reviewed on 8/2023, indicated Resident 1 was at risk for irregular heart rate related to low blood level of potassium. The interventions included to give medication as ordered. A review of Resident 22's Care Plan, developed on 5/15/2023 and last reviewed on 8/2023, indicated Resident 1 was at risk for seizure activity. The interventions included to give medications as ordered. On 10/18/2023 at 8:11 a.m., during a medication administration observation outside Resident 22’s room, LVN 1 prepared eight medications for Resident 22 including the following: - 15 ml (1500 ml) of Keppra and placed it in a medicine cup. - 10 ml (250 mg) of Dilantin and placed it in another medicine cup. - 15 ml of KCL 20 MEQ diluted with 200 ml water in a Styrofoam cup. During a concurrent observation at bedside and interview on 10/18/2023 at 9:05 a.m., LVN 1 added to the Styrofoam cup (with the KCl), the Keppra and the Dilantin and administered to Resident 22 through the GT. When asked, LVN 1 stated and verified that she poured the Dilantin and Keppra into the Styrofoam cup with the KCl diluted in 200 ml of water and administered them together via the GT. LVN 1 stated that she was trained "this way" on administration of medications to residents with GT but said she should have administered each medication one at a time. LVN 1 stated the medications may not be compatible and mixing them may result on adverse drug reaction placing Resident 22 at risk for serious medical complications. During an interview on 10/18/2023 at 3:00 p.m., LVN 1 stated she failed to follow the facility's P&P and standard of practice by mixing medications instead of giving Resident 22 one medication at a time. LVN 1 stated that she was "nervous," and it was her first time a surveyor followed her during medication administration. On 10/19/2023 at 9:21 a.m., during an interview, the Director of Staff Development (DSD) stated that newly hired LVNs without experience were trained on administering medications and GT administration for seven 12-hour shifts under the guidance of an experienced Licensed Nurses (LN) and LVN 1 was signed off as competent on 4/13/2023. The DSD stated the medication administration part on the Competency Orientation Training Checklist and RN/LVN Annual Skills Checklist did not specify competency for medication administration through GT. The DSD stated the DON conducts the LNs annual performance evaluations on the anniversary of the LN date of hire. During an interview on 10/20/2023 at 8:00 a.m., the Director of Nursing (DON) stated medications for GT administration should be given one at a time, to ensure there were no physical or chemical incompatibilities between medications and avoid placing the residents at risk for serious medical complications that may lead to hospitalization or death. The DON stated liquid medications should be administered directly into the GT unless there was a physician's order to dilute with water. On 10/20/2023 at 4:55 p.m., during an interview, the Medical Director (MD) stated antiseizure medications such as Keppra and Dilantin that are not administered properly, place the resident at risk for increased seizures. A review of the facility's P&P on Medication Pass via GT /Jejunostomy tube (JT, a soft tube inserted during surgery into the small intestine [bowel] through the belly to deliver food and medications), last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to pass medications through the GT / JT. The policy indicated to give medication as ordered one at a time. A review of the facility's P&P titled, "Medication Pass," last reviewed on 1/26/2023, indicated the purpose of the policy was to provide guidelines on how to properly complete medication pass. The policy indicated to give medications one at a time. 2. A review of Resident 43's Admission Record indicated the facility originally admitted the resident on 9/7/2016 with diagnoses including chronic respiratory failure, GT, anoxic brain damage (injuries caused by a complete lack of oxygen to the brain, which results in the death of brain cells), acute embolism (obstruction of an artery [type of blood vessel], typically by a clot of blood or an air bubble), and thrombosis (local clotting of the blood in a part of the circulatory system [system that circulates blood through the body: the heart, blood vessels, and blood]). A review of Resident 43's MDS, dated 10/4/2023, indicated Resident 43 rarely or never understood, was unable to make decisions, and required total staff assistance with ADLs. A review of the Physician's Orders for Resident 43, indicated the following: - Flush 50 ml of water via GT before and after medication administration and 5 to 10 ml in between medications, ordered on 9/9/2016. - Vitamin D 1,000 international units (IU - a unit of measurement) via GT every day for supplement, ordered on 1/19/2018. - Tums (medication used to relieve heartburn) 750 mg per tablet, one tablet via GT every 12 hours, ordered on 8/14/2018. - Multivitamins with minerals one tablet via GT every day for supplement, ordered on 4/15/2019. - Vitamin C 500 mg via GT every 12 hours for supplement, ordered on 7/25/2019. - Xarelto (rivaroxaban, blood thinner to treat and prevent blood clots) 10 mg via GT every day to prevent for deep vein thrombosis (DVT - a blood clot in a deep vein, usually in the legs), dated 9/23/2019. On 10/18/2023, at 9:04 a.m. during a medication administration observation and concurrent interview, LVN 2 was outside Resident 43's room reviewing Resident 43's medication administration record (MAR). LVN 2 stated Resident 43 was going to receive the following medications through the GT: - Tums 750 mg - Vitamin D 1,000 IU - Multivitamins with minerals one tab - Vitamin C 500 mg - Xarelto 10 mg LVN 2 placed each medication in a medication cup, then proceeded to transfer each medication into separate clear packets and crushed each one using a pill grinder. Then, placed the crushed contents of each packet into separate medicine cups. At 9:20 a.m., at bedside, LVN 2 used a piston syringe (a medical device that consists of a calibrated hollow barrel and a movable plunger) poured approximately 5 to 10 ml of water into five small clear plastic cups containing crushed medications and mixed the contents of each cup separately. LVN 2 drew up the mixture from one of the five cups using the piston syringe, connected the piston syringe barrel to the GT, and slowly pushed the medication using the syringe plunger. Prior to the first medication administration, LVN 2 did not administer 50 ml of water through Resident 43's GT as ordered by the physician. LVN 2 repeated the same process for the remaining four medications. LVN 2 did not administer 5 to 10 ml of water into Resident 43's GT between each medication administered as per physician's order. On 10/18/2023, at 9:26 a.m., after completing the medication pass, a concurrent interview with LVN 2 and a review of Resident 43's MAR which indicated to flush 50 ml of water via GT before and after medication administration and 5 to 10 ml in between medications. LVN 2 stated she forgot to flush Resident 43's GT with 50 ml of water before administering the medications and confirmed not flushing the GT with 5 to 10 ml between the five medications. LVN 2 stated it was important to flush a GT prior to administering medications to check for patency (open or unobstructed) and to prevent clogging. LVN 2 explained that since she had a lot of medications to administer, she did not want to take time in flushing water between each medication. LVN 2 stated she sometimes administers water between each medication, but only if the medication is sticky. LVN 2 stated it is important to administer water between each medication to prevent the medications from clogging the GT. Further review of Resident 43's MAR did not indicate Resident 43 had an order for gentle pushes to administer medications and was confirmed by LVN 2. LVN 2 stated she did not administer Resident 43's medication by gravity. During an interview, on 10/20/2023, at 12:05 p.m., the DON stated that prior to medication administration, the nurses needed to review the resident's MAR for instructions on which medications needed to be administered and how the medications were to be administered. The DON stated the GT needed to be flushed with 50 ml of water prior to medication administration and medications needed to be administered one at a time, by gravity. The DON stated it was not appropriate to push medications into the GT with the piston syringe because it could result on erupting (spilled) if the GT the syringe dislodged, or the resident may aspirate (liquid go into the airway) if the medication was pushed fast. The DON stated 5 to 10 ml of water is needed to be flushed between each medication to make sure there were no drug interactions and to prevent the GT from clogging. On 10/20/2023, at 4:55 p.m., during an interview, the MD stated flushing the GT with water before, between, and after medication administration was a standard practice. The MD stated administering water is done to make sure the medication is distributed properly, if water is not flushed between each medication, it was possible residual medication (in the tubing) would not reach its destination. A review of the facility's P&P titled, Gastrostomy Tube Water Flush, reviewed 1/26/2023, indicated the procedure for water flush: - Insert syringe into the end of the GT - Pour water into syringe - Allow water to flow by gravity into stomach - Hold about 12 to 18 inches (unit of measurement) above the opening - Flush 50 ml prior to medication administration, then flush 5 to 10 ml between each medication or per physician's order. A review of the facility's P&P on Medication Pass Via GT / JT, reviewed on 1/26/2023, indicated to flush the tube as ordered before and after medication administration. The P&P further indicated adults are given medications as ordered one at a time with 5 to 10 ml in between each medication or as per physician's orders. 3. A review of Resident 68's Admission Record indicated the facility admitted the resident on 10/28/2019 with diagnoses including anoxic brain damage, tracheostomy, and hypertension (a condition in which the blood vessels have persistently raised pressure). A review of Resident 68's H&P exam, dated 3/1/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 68's MDS, dated 10/16/2023, indicated the resident had severely impaired cognition, had a GT for feeding, and was dependent on staff for all ADLs. A review of the Physician's Orders for Resident 68 indicated the following medications: - Colace (stool softener) 100 mg via GT, every 12 hours for bowel management, hold for loose stool, ordered on 4/26/2023. - Glycopyrrolate (Robinul, anticholinergic medication) 2 mg via GT, every 8 hours for secretions, ordered on 3/1/2023. - Magnesium oxide (mineral supplement used to prevent and treat low amounts of magnesium in the blood) 400 mg via GT every day, ordered on 3/1/2023. - Vitamin D 2,000 IU via GT every day for suppl