Other·December 15, 2023

Health and Safety Code 1424(f)(1) & (f)(2) - Willful Material Falsification (WMF) (f)(1) Any willful material falsification or willful material omission in the health record of a patient of a long-term health care facility is a violation. (2) “Willful material falsification.” As used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to tests and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the resident or the care or services provided. On 10/30/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its Annual Recertification Survey. The facility failed to maintain accurate medical records and failed to ensure Licensed Vocational Nurse 2 (LVN 2) and other LVNs, who were acting as employees and agents of the facility in their duties - administering medications to residents, did not knowingly and willfully falsify the medical records of Resident 112 and Resident 14 by: 1. LVNs falsely documenting (with their name initials) on Resident 112’s Medication Administration Record (MAR) indicating the medication Isosorbide (works by relaxing and widening blood vessels so blood can flow more easily to the heart) was administered to Resident 112, from 10/20/2023 to 10/31/2023 (a total of 12 occurrences/medication administrations), when the medication had not been delivered to the facility by the facility’s contracted pharmacy since 10/19/2023, the date on which Resident 112’s physician ordered the Isosorbide. 2. LVN 2 falsely documenting on Resident 14’s MAR on 10/31/2023 that Resident 14 was administered the ordered apixaban (also known as Eliquis - a medication that helps to prevent blood clots) which was not available at the time of the medication pass. As a result, the medical records of Resident 112 and Resident 14 had falsely reflected care or services provided. In this case, LVN 2 and other LVNs falsified the administration of Isosorbide to Resident 112 and LVN 2 falsified the administration of apixaban to Resident 14. 1. A review of Resident 112's Admission Record indicated the facility admitted the resident on 10/19/2023 with diagnoses including hypertension and atrial fibrillation (a type of arrhythmia, or abnormal heart rhythm, that causes the heart to beat irregularly). A review of the Physician’s Order for Resident 112, dated 10/19/2023, indicated to administer Isosorbide 240 milligrams (mg) by mouth daily at 9:00 a.m. (morning shift) for hypertension. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, LVN 2 stated she gave Resident 112 Isosorbide the day prior (10/31/2023) as scheduled (9:00 a.m.). When LVN 2 was asked to show Resident 112's bubble pack (a card that packages medication per dose within a transparent plastic bubble) for Isosorbide, LVN 2 stated she could not find it and Resident 112 did not have any Isosorbide tablets available. On 11/1/2023 at 2:26 p.m., during a concurrent observation and interview, the surveyor contemporaneously observed Registered Nurse 1 (RN 1) call the facility’s contracted pharmacy. RN 1 spoke with Certified Pharmacy Technician 1 (CPhT 1), who indicated Resident 112's Isosorbide medication was never processed or delivered to the facility. On 11/1/2023 at 2:36 p.m., during a concurrent interview with LVN 2 and a review of Resident 112's MAR for 10/2023, LVN 2 stated she along with the other licensed nurses verified with their initials that they had administered Resident 112 Isosorbide from 10/20/2023 to 10/31/2023, a total of 12 occurrences/medication administrations. On 11/2/2023 at 1:51 p.m., during an interview, Registered Nurse 2 (RN 2) stated if nurses document their initials on the MAR, it means the medication was administered. RN 2 stated, in this case, given nurses were signing that they had administered Resident 112's Isosorbide from 10/20/2023 to 10/31/2023 even though they had not, Resident 112 could have suffered from adverse consequences from not receiving the medication, such as uncontrolled blood pressure or a stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). 2. A review of Resident 14's Admission Record indicated the facility readmitted Resident 14 on 8/22/2022 with diagnoses including right heart failure and atrial fibrillation. A review of the Physician's Order for Resident 14, dated 8/23/2022, indicated to administer one tablet of apixaban 2.5 mg by mouth one time a day for atrial fibrillation. On 10/31/2023 at 9:03 a.m., during a medication administration observation, LVN 2 was observed administering scheduled medications to Resident 14. There was an empty bubble pack of apixaban for Resident 14 and LVN 2 explained they ran out of the apixaban and would follow-up with the pharmacy to deliver it. LVN 2 did not administer the scheduled apixaban to Resident 14 on 10/31/2023. On 10/31/2023 at 9:27 a.m., at the conclusion of the medication administration for Resident 14, LVN 2 was observed entering her initials in the MAR for each of the medications scheduled for 9:00 a.m. including apixaban. When LVN 2 was asked why she documented the administration of apixaban to Resident 14, in the MAR, LVN 2 stated she did not want to leave blank spaces in the MAR. LVN 2 stated that if Resident 14's prescribed apixaban was delivered to the facility later in the day, then she would give the medication to Resident 14. LVN 2 stated that if Resident 14's apixaban medication was not administered during the medication pass, the expectation was that she would circle her initials, indicating the medication was not given to the resident. On 11/2/2023 at 1:51 p.m., during an interview, RN 2 stated that if nurses signed their initials on a resident's MAR, it meant that the medication was administered. RN 2 stated that nurses should not sign the MAR if a medication was not given. RN 2 stated if a medication is not available, then nurses should make a note in their MAR entry, otherwise subsequent licensed nurses assigned to care for the resident could become confused as to whether a medication had been administered to a resident. A review of the facility's policy and procedure (P&P) titled, "Administering Medications," last reviewed by the facility on 10/11/2023, indicated that the licensed nurses administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. A review of the facility's P&P titled, "Documentation of Medication Administration," last reviewed by the facility on 10/11/2023, indicated that administration of medication must be documented immediately after (never before) it is given. The facility failed to maintain accurate medical records and failed to ensure LVN 2 and other LVNs, who were acting as employees and agents of the facility in their duties - administering medications to residents, did not knowingly and willfully falsify the medical records of Resident 112 and Resident 14 by: 1. LVNs falsely documenting (with their name initials) on Resident 112’s MAR indicating the medication Isosorbide was administered to Resident 112, from 10/20/2023 to 10/31/2023 (a total of 12 occurrences/medication administrations), when the medication had not been delivered to the facility by the facility’s contracted pharmacy since 10/19/2023, the date on which Resident 112’s physician ordered the Isosorbide. 2. LVN 2 falsely documenting on Resident 14’s MAR on 10/31/2023 that Resident 14 was administered the ordered apixaban which was not available at the time of the medication pass. As a result, the medical records of Resident 112 and Resident 14 had falsely reflected care or services provided. In this case, LVN 2 and other LVNs falsified the administration of Isosorbide to Resident 112 and LVN 2 falsified the administration of apixaban to Resident 14. The above facts indicate there were willful material falsifications in the medical records of Residents 112 and 14.