Other·May 3, 2024

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 3/18/2024, 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 clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN) 1 did not willfully falsify (alter [information or evidence] so as to mislead) entries in Resident 17's Medication Administration Record (MAR) by documenting the administration of Ambien (sleep aid), gabapentin (treats nerve pain), and simvastatin (treats high cholesterol) on 3/14/2024 at 9:00 p.m. when LVN 1 did not administered those medications. 2. Ensure LVN 1 did not willfully falsify entries in Resident 18’s MAR by documenting a heart rate of 75 beats per minute (bpm) on 3/19/2024 that LVN 1 did not measure before giving a medication as indicated in the physician's order. As a result, the medical records of Resident 17 and Resident 18 falsely reflected care or services provided. Resident 17's medical record indicated receiving Ambien, gabapentin, and simvastatin when these medications were not administered. Resident 18’s medical record indicated the heart rate was measured prior to the administration of metoprolol (treats high blood pressure) when the heart rate was not measured before the medication administration. a. A review of Resident 17's Admission Record indicated the facility admitted the resident on 9/3/2021 and readmitted the resident on 1/8/2024 with diagnoses that included polyneuropathy (disease or dysfunction of one or more peripheral nerves [nerves located outside of the brain and spinal cord], typically causing numbness or weakness), hyperlipidemia (elevated blood cholesterol), and chronic pain. A review of Resident 17's Physician Orders I dated 1/8/2024 indicated the following: -Ambien 10 milligrams (mg) tablet, give one tablet by mouth before bedtime for insomnia (persistent problems falling and staying asleep) manifested by inability to sleep. -Gabapentin 300 mg capsule, give one capsule by mouth at bedtime for neuropathy (nerve pain). - Simvastatin 20 mg tablet, give one tablet by mouth at bedtime. On 3/18/2024 at 3:47 p.m., during a concurrent interview with LVN 2 and a review of Resident 17's Record of Controlled Substances (RCS, medications with potential for abuse, and may lead to physical or psychological dependence) form for Ambien, a review of the MAR for the month of 3/2024, and observation of the Ambien bubble pack (a package that contains multiple sealed compartments with medication), LVN 2 stated Ambien was a controlled substance kept in a locked drawer. LVN 2 stated the RCS form is completed when the medication is removed from the bubble pack prior to administration. The MAR is used to document the medication after it is administered. LVN 2 noted that Resident 17's RCS form for Ambien indicated Ambien was not removed on 3/14/2024. LVN 2 stated the number of tablets remaining in the bubble pack matched the number of tablets documented in the RCS form; however, LVN 1 documented in the MAR that Ambien was administered to Resident 17 on 3/14/2024 at 9:00 p.m. On 3/19/2024 at 3:00 p.m., during a concurrent interview with LVN 1 and a review of Resident 17's RCS form for Ambien, a review of the MAR for the month of 3/2024, and an observation of the Ambien bubble pack, LVN 1 stated she did not administer Resident 17's Ambien but documented its administration. LVN 1 stated on 3/14/2024 she was called in to work to administer medications and when she arrived around 9:00 p.m. Resident 17 told her medications were already given. LVN 1 also documented that gabapentin and simvastatin were scheduled and administered at 9:00 p.m. LVN 1 acknowledged Resident 17's MAR was not accurate because she documented medications she did not give. During an interview on 3/19/2024 at 4:20 p.m., the Director of Nursing (DON) stated licensed nurses should not document in the MAR, medications they did not personally administer as indicated in the facility's policies and procedure (P&P) on Medication Administration and Charting and Documentation. The DON stated LVN 1 falsified Resident 17's MAR. b. A review of Resident 18's Admission Record indicated the facility admitted the resident on 1/10/2023 with diagnoses that included hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time, and results in heart failure in which the heart does not pump blood to the body effectively). A review of Resident 18's Physician Orders, dated 1/1/2024, indicated to give metoprolol 25 mg one tablet twice daily through the gastrostomy tube (GT, a flexible tube inserted into the stomach through the abdominal wall to administer food and medications for a person unable to swallow). Hold if the systolic blood pressure (SBP - the first number in a blood pressure reading) is less than 110 millimeters of mercury (mmHg) or the heart rate is less than 60 beats bpm. On 3/19/2024 at 8:02 a.m., during a medication pass observation for Resident 18, LVN 1 prepared and administered Resident 18's medications without taking Resident 18's heart rate but later documented in the MAR that Resident 18's heart rate prior to administration of metoprolol was 75 bpm. On 3/19/2024 at 2:10 p.m., during an interview with LVN 1 in the presence of the DON and a concurrent review of Resident 18's MAR for 3/19/2024, LVN 1 stated she overlooked taking the heart rate prior to administering metoprolol so she went back afterwards and took Resident 18's heart rate. She then documented the heart rate in the MAR. LVN 1 stated she did not see the order indicating a heart rate was needed until she was documenting the medication in the electronic health record, and she clicked "review and sign." LVN 1 stated she did not add any note indicating this heart rate was taken after the metoprolol was given and not before as ordered by the physician. A review of the facility's policy and procedure titled, "Medication Administration," last reviewed 2/28/2024, indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed by the state to prepare, administer, and document the administration of medications may do so. A review of the facility's policy and procedure titled, "Charting and Documentation," last reviewed 2/28/2024, indicated all services provided to the resident shall be documented in the resident's medical record. The medical record shall facilitate communication between the interdisciplinary team (IDT, a group of disciplines such as nursing, dietary, and social services that meet to discuss a resident's plan of care) regarding the resident's condition and response to care. Information regarding medications administered is to be documented in the resident medical record. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure LVN 1 did not willfully falsify entries in Resident 17's MAR by documenting the administration of Ambien, gabapentin, and simvastatin on 3/14/2024 at 9:00 p.m. when LVN 1 did not administered those medications. 2. Ensure LVN 1 did not willfully falsify entries in Resident 18’s MAR by documenting a heart rate of 75 bpm on 3/19/2024 that LVN 1 did not measure before giving a medication as indicated in the physician's order. As a result, the medical records of Resident 17 and Resident 18 falsely reflected care or services provided. Resident 17's medical record indicated receiving Ambien, gabapentin, and simvastatin when these medications were not administered. Resident 18’s medical record indicated the heart rate was measured prior to the administration of metoprolol when the heart rate was not measured before the medication administration. The above facts indicate there was willful material falsification in the medical records of Residents 17 and 18.