Health inspection·November 20, 2024

F759 §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 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. On 10/1/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the annual recertification survey. The facility failed to: 1. Reorder medications five days in advance of need to assure an adequate supply was on hand (current availability) as per facility policy for Residents 5 and 31. 2. Follow-up for delivery and availability of medications for Residents 5 and 31. 3. Remove, destroy and not use another resident's medication (Resident 18, a discharged resident) to provide Eliquis (a medication used for cerebrovascular accidents [CVA, also known as stroke, a loss of blood flow to part of the brain, which damages brain tissue]) to Resident 31 from 9/1/2024 to 9/30/2024. 4. Maintain a medication error rate below five percent (% - one part in every hundred) by having seven medication errors out of 26 medication administration opportunities contributing to an overall error rate of 26.92% affecting Residents 5 and 31. The medication errors were as follows: a. Resident 5 did not receive the following medications as ordered by Resident 5's physician: - two doses on 10/1/2024 at 9 a.m. and 5 p.m. of metoprolol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) - one dose on 10/1/2024 at 8 a.m. of bumetanide (a medication used for edema [swelling of feet, ankles, legs, and other parts of the body, such as the face, hands, and abdomen caused by fluid retention]) b. Resident 31 did not receive the following medications, as ordered by Resident 31's physician: - two doses on 10/1/2024 at 9 a.m. and 5 p.m. of Eliquis, - two doses on 10/1/2024 at 9 a.m. and 5 p.m. of brimonidine (a medication used for glaucoma [a condition of increased pressure in the eyeball]), - one dose on 10/1/2024 at 9 a.m. of finasteride (a medication used for benign prostatic hyperplasia ([BPH] - a condition in men where the prostate gland - a small gland located inside the groin - is enlarged), - one dose on 10/1/2024 at 9 a.m. of folic acid (a medication used for anemia [a condition with lower-than-normal number of red blood cells]), - one dose on 10/1/2024 at 9 a.m. of tamsulosin (a medication used for BPH) As a result: 1. Resident 5 did not receive two doses on 10/1/2024 at 9 a.m. and 5 p.m. of metoprolol and one dose on 10/1/2024 at 8 a.m. of bumetanide on 10/1/2024, increasing the potential to cause Resident 5 serious harm, serious impairment, and serious complications, potentially resulting in elevated blood pressure, hospitalization, and/or death. 2. Resident 31 did not receive two doses on 10/1/2024 at 9 a.m. and 5 p.m. of Eliquis, two doses on 10/1/2024 at 9 a.m. and 5 p.m. of brimonidine, one dose on 10/1/2024 at 9 a.m. of finasteride, one dose on 10/1/2024 at 9 a.m. of folic acid, and one dose on 10/1/2024 at 9 a.m. of tamsulosin increasing the potential to cause Resident 31 serious harm, serious impairment, and serious complications, potentially resulting in blood clots, blindness, stroke, hospitalization, and/or death. 3. Resident 31 received 60 doses of Eliquis between 9/1/2024 and 9/30/2024 from Resident 18's medication supply. A. During a review of Resident 5's Admission Record (a document containing demographic and diagnostic information), the Admission Record indicated Resident 5, a 94-year-old male resident, was originally admitted to the facility on 4/12/2016 and was re-admitted on 4/15/2023 with diagnoses including cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die,) atrial fibrillation (irregular heartbeat,) essential hypertension (high blood pressure that develops over time), and heart disease (a general term for conditions that affect the heart or blood vessels, and how they function which can lead to edema). During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 7/25/2024, the MDS indicated Resident 5 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, and lying to sitting on side of bed. The MDS also indicated Resident 5 needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds the trunk or limbs and provides more than half the effort) with chair/bed-to-chair transfers. During a review of Resident 5's IDT (Interdisciplinary Team (IDT - a team of health care professionals from different disciplines who work together to provide personalized care for residents) Care Plan Conference Summary, dated 10/2/2024, the IDT Care Plan Conference Summary indicated Resident 5 is forgetful, able to express (make self understood), and able to understand others. During a review of Resident 5's Physician Orders (a report listing the physician order for the resident) from 10/1/2024 to 10/31/2024, the Physician Orders indicated Resident 5 was prescribed the following: 1. Bumetanide 0.5 milligrams (mg - a measure of unit of mass) tablet by mouth once a day at 8 a.m. for fluid retention, starting 4/15/2023, 2. Metoprolol 25 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for hypertension, starting 7/13/2023. During a review of Resident 5's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for October 2024, the MAR indicated the following: 1. For 10/1/2024, there was no documentation noted in the MAR that Resident 5 was administered bumetanide 0.5 mg at 8 a.m. 2. For 10/1/2024, there was no documentation noted in the MAR that Resident 5 was administered metoprolol 25 mg at 9 a.m. and 5 p.m. During a medication administration observation on 10/1/2024 at 9:18 a.m. by Medication Cart 1, Licensed Vocational Nurse (LVN 1) was observed not administering the following medications to Resident 5: 1. Metoprolol 25 mg 2. Bumetanide 0.5 mg LVN 1 informed Resident 5 that the metoprolol and bumetanide were not available that morning (9:18 a.m.) and that Resident 5 would have to wait for the pharmacy to deliver the medication to administer later that day. During an interview on 10/1/2024 at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer metoprolol 25 mg on 10/1/2024 at 9 a.m. and bumetanide 0.5 mg on 10/1/2024 at 8 a.m. to Resident 5, since the medications were not available in the medication carts, in the facility or in the emergency kits ([eKIT] - a kit with limited supply of medications needed during emergent situations). LVN 1 stated that medications should be re-ordered from the pharmacy three to five days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated that by missing doses of those critical medications (such as metoprolol) it increased the risk that Residents 5 could experience high blood pressure and stroke possibly resulting in hospitalization and/or death. During an interview on 10/2/2024 at 1:35 p.m. with the Director of Nursing (DON), the DON stated that licensed nurses should ensure physician orders are followed and medications are administered at the scheduled times by following the five rights of medication administration, which includes: right patient, right drug, right dose, right time, right route. During an interview on 10/2/2024 at 2:01 p.m. with the DON, the DON stated that Resident 5 was not administered metoprolol 25 mg on 10/1/2024 at 9 a.m. and 5 p.m. and bumetanide 0.5 mg on 10/1/2024 at 8 a.m. due to the medications not being available. The DON stated those (metoprolol and bumetanide) medications were not available in the medication carts and not available in the eKIT. The DON stated Resident 5 was prescribed metoprolol for high blood pressure and bumetanide for edema. The DON stated missing the administrations of those critical medications (such as metoprolol) can cause elevated blood pressure by not maintaining normal pressures leading to potential stroke resulting in hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications within the three to five day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 5. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on 10/2/2024 at 3:19 p.m. with LVN 1, LVN 1 stated that he (LVN 1) was not able to administer the 5 p.m. dose of metoprolol 25 mg for Resident 5 on 10/1/2024 since the medication was not available. During an interview on 10/4/2024 at 8:44 a.m. with the Consulting Pharmacist (CP), the CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like metoprolol can potentially increase the risk of elevated heart rate and elevated blood pressure resulting in hospitalization. During a review of the facility's pharmacy delivery manifests (detailed statement or invoice for shipment of medications) faxed to the facility on 8/29/2024, the pharmacy delivery manifest indicated the facility received a 30-day supply of Resident 5's bumetanide 0.5 mg tablets on 8/29/2024 and did not receive an additional supply until 10/2/2024. During a review of the facility's pharmacy Consolidated Delivery Sheets (record that includes the medications delivered to the facility from the dispensing pharmacy) faxed to the facility on 8/28/2024, the Consolidated Delivery Sheets indicated the facility received a 30-day supply of Resident 5's metoprolol 25 mg tablets on 8/28/2024 and did not receive an additional supply until 10/2/2024. B. During a review of Resident 31's Admission Record, the Admission Record indicated Resident 31, a 97-year-old male resident, was originally admitted to the facility on 10/10/2023 with diagnoses including myocardial infarction (heart attack,) atrial fibrillation (irregular heartbeat,) BPH, hypertensive heart disease (heart disease caused by constant high blood pressure). During a review of Resident 31's MDS dated 7/18/2024, the MDS indicated Resident 31 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 31 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers. During a review of Resident 31's Physician Orders, from 10/1/2024 to 10/31/2024, the Physician Orders indicated Resident 31 was prescribed the following: 1. Eliquis 2.5 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for CVA prophylaxis (the prevention of disease or the measures taken to maintain health), starting 10/10/2023, 2. Brimonidine 0.2% one (1) drop each eye twice a day at 9 a.m. and 5 p.m. for glaucoma, starting 10/10/2023, 3. Finasteride 5 mg tablet by mouth once a day at 9 a.m. for BPH, starting 10/1/2024, 4. Folic acid 1 mg tablet by mouth once a day at 9 a.m. for anemia, starting 10/12/2023, 5. Tamsulosin 0.4 mg capsule by mouth once a day at 9 a.m. for BPH, starting 10/10/2023. During a review of Resident 31's MAR for October 2024, the MAR indicated the following: 1. For 10/1/2024, there was no documentation noted in the MAR that Resident 31 was administered Eliquis 2.5 mg at 9 a.m. and 5 p.m. 2. For 10/1/2024, there was no documentation noted in the MAR that Resident 31 was administered brimonidine 0.2% at 9 a.m. and 5 p.m. 3. For 10/1/2024, there was no documentation noted in the MAR that Resident 31 was administered finasteride 5 mg at 9 a.m. 4. For 10/1/2024, there was no documentation noted in the MAR that Resident 31 was administered folic acid 1 mg at 9 a.m. 5. For 10/1/2024, there was no documentation noted in the MAR that Resident 31 was administered tamsulosin 0.4 mg at 9 a.m. During a medication administration observation on 10/1/2024 at 8:49 a.m. with LVN 1 at Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 31: 1. Eliquis 2.5 mg tablet 2. Brimonidine 0.2% eye drops 3. Finasteride 5 mg tablet 4. Folic acid 1 mg tablet 5. Tamsulosin 0.4 mg tablet LVN 1 informed Resident 31 that the Eliquis, Brimonidine, finasteride, folic acid, and Tamsulosin were not available and that Resident 31 would have to wait for pharmacy to deliver the medications to administer later that day. During an interview on 10/1/2024 at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer Eliquis 2.5 mg and brimonidine 0.2%, finasteride 5 mg, folic acid 1 mg, and tamsulosin 0.4 mg on 10/1/2024 at 9 a.m. to Resident 31, since the medications were not available in the medication carts or in the facility. LVN 1 stated that those medications were not available in the eKIT either. LVN 1 stated that he (LVN 1) will follow-up with the pharmacy for the refill of those (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) medications and inform the physicians that the morning doses on 10/1/2025 were not administered to Resident 31. LVN 1 stated that medications should be re-ordered from the pharmacy three to five days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated missing doses of those critical medications (such as Eliquis, brimonidine) can harm Resident 31 by causing increased eye pressures, another CVA, and stroke resulting in hospitalization and/or death. During a concurrent observation and interview on 10/1/2024 at 1:35 p.m. by Medication Cart 1 with LVN 1 and the DON, LVN 1 stated that due to the unavailability of Eliquis 2.5 mg from 9/1/2024 to 9/30/2024, LVN 1 used Resident 18's su