Health inspection·February 7, 2025

T22 § 72319. Nursing Service--Restraints and Postural Supports. (j) When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: (1) The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the patient's health record. (2) The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. (3) The data collected shall be made available to the prescriber in a consolidated manner at least monthly. (4) PRN orders for such drugs shall be subject to the requirements of this section. F758 §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic. (ii) Anti-depressant. (iii) Anti-anxiety; and (iv) Hypnotic. §483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a Patient, the facility must ensure that-- §483.45(e)(1) Patients who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. §483.45(e)(3) Patients do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. On 1/10/2025 at 2:30 PM, an unannounced visit was conducted by California Department of Public Health (CDPH) to investigate an allegation of restraints/seclusion- general. The facility failed to ensure management of Patient 1 ' s psychotropic medications met the psychotropic medication requirements, in accordance with the facility ' s policy and procedures (P&P) titled "Medication Utilization and Prescribing - Clinical Protocol," "Psychotropic Medication use," and "Appendix 3: Medication Issues Of Particular, Relevance In Older Adults" by failing to: 1. Ensure Patient 1 ' s Depakote (brand name as divalproex sodium, used to treat epilepsy and bipolar disorder, medication works by affecting chemicals in the brain) is given when necessary to treat a specific diagnosed and documented clinical condition, that was based upon a clinical assessment of the Patient ' s condition and consistent with clinical standards of practice. Patient 1 was administered Depakote for the treatment of seizures, despite the Patient not having a seizure disorder or diagnosis. Patient 1 ' s diagnosis for Depakote use was later changed to "Mood swings" on 12/18/2024, without adequate clinical assessment and/or a comprehensive review of the Patient that included an evaluation of the Patient's signs and symptoms to identify underlying causes. 2. Ensure the facility ' s licensed nurses adequately monitor and document the Depakote for efficacy and adverse consequences (side effects) from 12/11/2024 to 12/28/2024. 3. Prevent, identify, and respond to adverse consequences for the use of Depakote from 12/11/2024 to 12/27/2024, when Patient 1 was observed by LVN 1 and communicated by Responsible Party (RP) 1 to the facility staff as quiet, drowsy, sedated and with poor oral intake. 4. Ensure Licensed Vocational Nurse (LVN) 1 arrange a follow-up visit with the Psychiatrist to reevaluate Patient 1 ' s psychotropic medication/s, as ordered by Patient 1 ' s attending physician (MD)1 on 12/12/2024, until 12/27/2024. 5. Develop a comprehensive care plan for administration of Depakote from 12/11/2024 to 12/18/2024 that includes clear guidelines for medication management, such as ensuring proper dosage, schedule, and purpose (seizure control, mood stabilization, or migraine prevention). Document episodes of agitation, aggression, irritability, outburst of anger or unusual behavior. Also note any changes in the patient's typical behavior patterns. Regular monitoring for both common side effects (like drowsiness and weight loss, dehydration) and serious ones (such as liver damage and pancreatitis) is essential, along with routine lab tests for liver function, CBC, and renal health. These failures resulted to a delay in Patient 1 ' s management of Depakote adverse consequences that included abdominal pain, drowsiness, poor oral intake. Patient 1 was transferred to the General Acute Care Hospital (GACH) 2 on 12/29/2024 discharged on 1/3/2025 with diagnoses that included lower gastrointestinal (GI) bleed, hypernatremia, and dehydration. During a review of Patient 1, a 94 years old female’s Face Sheet (admission record) indicated the Patient was admitted to Facility 1 on 10/31/2024 with diagnoses of unspecified Dementia, unspecified severity, without behavior disturbances , psychotic disturbance , mood disturbance , and anxiety(Memory loss, difficulty with problem-solving or planning, confusion about time or place, and problems with speaking or writing without psychosis (loss from reality ), anxiety disorder unspecified(a diagnosis given to people who have symptoms of anxiety panic attack, inability to stay still and anxiety significant enough to be distressing but does not meet the criteria for another anxiety disorder), insomnia(persistent problems falling and staying asleep). During a review of Patient 1 ' s History and Physical (H&P), dated 11/05/2024, the History and Physical indicated Patient 1 has fluctuating capacity to understand and make decisions. The H&P did not indicate Patient 1 had a history or diagnosis of seizures. During a review of Patient 1's Minimum Data Set (MDS, a federally mandated Patient assessment tool), dated 11/04//2024, the MDS indicated Patient 1 cognition severely impaired (significant loss or reduction in a person ' s cognitive abilities, such as memory, reasoning, problem-solving, attention, and language, which severely interfere with the individual ' s ability to function normally in everyday life, including performing basic tasks, making decisions, or communicating effectively. During a review of Patient 1 ' s Change of Condition (COC), dated 12/08/2024 timed at 4:07 PM, the COC indicated Patient 1 complained of abdominal pain, noted with distended abdomen (a swollen and enlarged abdomen, often accompanied by a feeling of fullness and bloating), with active peristalsis heard using the stethoscope (sound of a series of muscle contractions that move food through your digestive tract). The COC indicated the Patient complained of pain when defecating. The COC indicated Patient 1 was on monitoring for dysuria and recent urinalysis (a test that analyzes a person's urine to detect various health conditions) result, did not indicate an infection. The COC indicated a recommendation transfer to the acute hospital (GACH 1). The COC indicated Patient 1 was transferred to GACH 1 on 12/8/2024. During a review of Patient 1 ' s GACH 1 record titled "History and Physicals" dated 12/9/2024 electronically signed by MD 1 at 11:18 PM, the GACH 1 record under "Diagnoses," indicated to admit Patient 1 to GACH 1 for chest pain, constipation, elevated troponin and under "Plan" for cardiac work up, milk of magnesia, Dulcolax suppository, enema and Depakote for her psychosis. During a review of Patient 1 ' s GACH 1 record titled "Orders-Medication- Inpatient medications," the GACH 1 record indicated Patient 1 last received divalproex sodium (Depakote) on 12/10/2024 at 9:03 AM, 12/10/2024 at 3:10 PM, and 12/10/2024 at 8:19 PM, as ordered by MD 1 on 12/09/2024 timed at 11:13 PM. During a review of Patient 1 ' s GACH 1 record titled "Discharge summary" electronically signed on 12/13/2024, the GACH 1 record indicated Patient 1 was transferred to the GACH on 12/08/2024 with an admitting diagnosis of chest pain. The GACH Discharge Summary indicated Patient 1 was discharged back to the facility on 12/10/2024, with GACH 1 discharge medications that included "Depakote EC 250 mg 1 tablet daily three times a day." During a review of Patient ' s 1 Facility 1 ' s Telephone Order Summary dated 12/18/2024 and timed at 12:36 PM, authored by the ADON, the order indicated the Depakote oral tablet delayed release was changed (decreased) to 125 mg, one tablet by mouth every 12 hours for mood swings manifested by sudden outbursts of anger related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. During a review of Patient ' s 1 Facility 1 Telephone Order Summary dated 12/26/2024 and timed at 12:39 PM, authored by LVN 1, the order indicated the Depakote oral tablet delayed release 125 mg, one tablet by mouth every 12 hours for mood swings was discontinued "Per (Responsible Party [RP] 1) request." During a review of Patient 1 ' s Medication Administration Records (MAR), dated 12/1/2024 to 12/31/2024, the MAR indicated the Patient received: -Divalproex Sodium (Depakote) 250 mg 1 tablet oral tablet 3 times a day for seizure that started from 12/11/2024 to 12/17/2024 and 1 tablet on 12/18/2024 at 9:00 AM. The MAR order indicated the Divalproex Sodium or Depakote was discontinued on 12/18/2024 timed at 12:36 PM. There was no documented evidence Patient 1 was monitored for side effects of Depakote and was monitored for any seizures from 12/11/2024 to 12/18/2024. - Divalproex Sodium (Depakote) 125 mg 1 tablet oral every 12 hours times a day for mood swings M/B sudden outbursts of anger related to unspecified dementia. Unspecified severity, without behavioral disturbance, psychotic disturbance that started from 12/19/2024 to 12/25/2024 and 1 tablet was received on 12/26/2024 at 9:00 AM. The MAR order indicated the Divalproex Sodium or Depakote was discontinued on 12/26/2024 timed at 12:38 PM. The MAR indicated an order to monitor Patient 1 for mood swings manifested by sudden anger outbursts every shift for the use of Depakote. The MAR indicated Patient 1 had episodes of anger outbursts on 12/19/2024 during the AM shift (7 am to 3 pm), no episodes of anger outbursts on 12/20/2024, 12/21/2024, 12/22/2024, 12/23/2024, 12/24/2024. The MAR further indicated Patient 1 had episodes of anger outbursts on 12/25/2024 during the AM shift, PM shift (3 pm to 11 pm) and night shift (11 pm to 7 am). The MAR indicated Patient 1 had episodes of anger outburst on 12/26/2024 during the AM shift and no episodes on 12/27/2024 and 12/28/2024. During a review of Patient 1 ' s Nurses Note, dated 12/12/2024 at 2:04 PM, as authored by MD 1, the Nurses Note indicated visited by MD 1 in the facility with the following order: "Follow up with Psych (Psychiatrist)." The Patient ' s records did not indicate there was a physician order transcribed that indicated Patient 1 was referred back to the Psychiatrist for an evaluation or reevaluation during Patient 1 ' s readmission back to the facility from 12/11/2024 to 12/28/2024. During a review of Patient 1 Change of Condition (COC), dated 12/26/2024 and timed 11:42 AM, the COC indicated "Poor PO intake." The COC indicated "Patient (Patient 1) not consuming any of her meals on her own or by being fed." The COC indicated MD 1 was notified by leaving a voicemail message but "Awaiting reply." The Patient ' s records did not indicate an actual physician order or documented evidence of MD 1 ' s response to Patient 1 ' s COC for 12/26/2024. During a review of Patient 1 ' s Nurses Note, dated 12/26/2024 at 12:39 PM, the Nurses Note indicated "MD 1 replied with new orders to stop Depakote." There was no documented evidence that indicated a physician order on 12/26/2024 was transcribed to discontinue Patient 1 ' s Depakote due to drowsiness. During a review of Patient 1 ' s Psychiatric Progress Note dated, 12/27/2024, the Psychiatric Progress Note indicated, "Depakote was discontinued because patient has been having poor oral intake and drowsier." During a review of Patient 1 Change of Condition (COC), dated 12/28/2024 and timed 11:55 PM, the COC indicated "Patient has increased confusion during the shift." During a review of Patient 1 ' s GACH 2 records, titled "Discharge Summary" dated 1/12/2025 at 3:05 PM indicated Patient 1 was admitted to GACH 2 on 12/29/2024 with admitting diagnoses of dehydration, hypernatremia, and lower GI bleed and was discharged to another facility (Facility 2) on 1/03/2025. During an interview on 1/10/2025 at 2:10 PM with Patient 1 ' s Responsible Party (RP) 1, RP 1 stated Patient 1 does not have a diagnosis of seizure. RP 1 stated the Assistant Director of Nursing (ADON) informed him that Depakote was ordered at GACH 1 on 12/10/2024 and it has to be continued. RP 1 stated when he visited Patient 1 at the facility from 12/11/2024 to 12/26/2024, he had observed Patient 1 drowsy, poor intake, and sedated. RP 1 stated he asked MD 1, ADON, and LVN 1 continuously since 12/11/2024, to discontinue the Depakote but the facility staff did not evaluate Patient 1 after informing them many times that Patient 1 looks sedated from the new medication ordered from GACH 1 (Depakote). RP 1 stated the facility only decreased the dose and finally discontinued the Depakote on 12/26/2024. During an interview and record review of Patient 1's MAR for the month of December 2024 on 1/10/2025 at 2:50 PM, with LVN 1, LVN 1 stated since Patient 1 was readmitted back to the facility from GACH 1 on 12/11/2024, LVN 1 stated he observed Patient 1 was quiet, drowsy and with poor oral intake. LVN 1 stated RP 1 had requested him and the Assistant Director of Nursing (ADON) to stop the Depakote. LVN 1 stated that according to the MAR, Patient 1, received Depakote 250 mg 1 tablet oral, 3 times a day for diagnosis of seizure from 12/11/2024 to 12/17/2024 and 1 tablet on 12/18/2024 at 9:00 AM and the Psych MD decreased the Depakote dose on 12/18/2024, to Depakote 125 mg, 1 tablet orally every 12 hours and changed the indication from a diagnosis of seizures to an indication of "Mood swings, manifested by sudden outbursts of anger related to unspecified dementia," however, Patient 1 continued to be drowsy. LVN 1 stated the MAR indicated Patient 1 received Depakote 12 mg tablet, every 12 hours from 12/19/2024 to 12/25/2024 and 1 tablet on 12/26/2024 at 9:00 AM for unspecified dementia without behavioral disturbance. LVN 1 stated that it was MD 1 (not Psych MD) who discontinued the Depakote order (125 mg) on 12/26/2024. LVN 1stated since Patient readmitted from hospital on 12/11/2024, LVN 1 stated he observed Patient 1 was quiet, drowsy with poor intake stated RP requested him and Assistant Director of Nursing (ADON) to stop the Depakote. LVN 1 stated the Psych MD decreased the Depakote dose on 12/18/2024, however, Patient 1 continued to be drowsy. LVN 1 stated MD 1 discontinued the Depakote order on 12/26/2024. LVN 1 stated he could not find documentation and could not recall the date that MD 1 was informed about Patient 1 being drowsy and sedated. During a concurrent interview and record review on 1/10/2025 at 3:01 PM with LVN 1, Patient 1 admitting Diagnosis, nurses note, MD order, and MAR for the month of December 2024, was reviewed. LVN 1 stated Patient 1 does not have diagnosis of seizure, stated he is unable to find documented evidence the indication of the use of medication from 12/11/2024 to 12/18/2024 also unable to find documented evidence to monitor side effect of Depakote from 12/11/2024 to 12/26/2024. LVN 1 stated it is important to know what kind of behavior to monitor to track Patient ' s progress to know if medication is effective or even the Patient needs that medication. LVN 1 stated it is important to monitor Medication side effects to inform MD. During an interview and record review on 1/10/2025 at 3:49 PM with ADON, Patient 1 ' s Interdisciplinary Team (IDT) Behavior Management, dated 12/18/2025 at 12:29, reviewed. The IDT Behavior Managment indicated Patient has no episodes of inability to sit still. Only issues with anger outbursts but rarely. Psychiatrist ordered to decrease Depakote to 125mg by mouth every 12 hours. The ADON stated based on his observation Patient 1 was calm from 12/11/2024 to 12/18/2024 but still experience outburst of anger, so he reports the symptoms by phone to Psychiatrist and the psychiatrist placed a tel