Other·November 17, 2023

The facility must ensure that its— 42 CFR §483.45(f)(2) Residents are free of any significant medication errors. On 10/2/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility the annual recertification survey. The facility failed to ensure Residents 54, 36, 52, 49, 47, and 2 were free from significant medication error (one which causes the resident discomfort or jeopardizes his or her health and safety) by not ensuring: 1. Amlodipine besylate (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order with a parameter to hold (do not give) the medication if Resident 54's systolic blood pressure (SBP, measures the pressure in the arteries [pathway that carries blood away from the heart] when the heart beats) was less than 110 millimeters of mercury (mmHg). 2. Carvedilol (medication to treat high blood pressure) was administered in accordance with the physician's order with a parameter to hold if Resident 36's SBP was less than 120 mmHg. 3. Metoprolol tartrate (medication to treat high blood pressure) was administered in accordance with the physician's order with a parameter to hold if Resident 52's SBP was less than 100 mmHg and the heart rate (HR) was less than 60 beats per minute (bpm). 4. Amiodarone (medication which relaxes the blood vessels to increase the supply of blood to the heart) was administered in accordance with the physician's order with a parameter to hold if Resident 49’s HR was less than 60 bmp and that isosorbide mononitrate (medication which relaxes the blood vessels to increase the supply of blood to the heart) was held if the SBP was less than110 mmHg and the HR less than 55 bpm. 5. Amiodarone was administered in accordance with the physician's order with a parameter to hold if Resident 47’s HR was less than 60 bmp. 6. Admelog (a hormone that works by lowering levels of sugar [BS] in the blood) was administered to Resident 2 in accordance with the physician's order to hold the medication if the residents BS was below 100 milligrams per deciliter (mg/dL). As a result, Residents 54, 36, 52, 49, and 47 were placed at risk for hypotension (low blood pressure) which could lead to dizziness, headache, fainting, blurred vision, shallow breathing, and injury from falls and Resident 2 was placed at risk for experiencing hypoglycemia (low BS level) which may result in confusion, heart palpitations, shakiness, and anxiety. 1. A review of Resident 54's Admission Record indicated the facility admitted the resident on 11/2/2018 and readmitted the resident on 8/2/2023 with diagnoses including hypertension (high blood pressure). A review of Resident 54 Physician’s Order, dated 8/2/2023, indicated to give the resident amlodipine besylate 2.5 milligrams (mg) tablet one time a day for hypertension and hold for SBP less than 110 mmHg. On 10/3/2023 at 3:52 p.m., during a concurrent interview with Licensed Vocational Nurse 4 (LVN 4) and a review of Resident 54's Medication Administration Record (MAR) for the month of 9/2023 indicated Resident 54 was administered amlodipine on 9/2/2023 and 9/20/2023 at 9 a.m., when Resident 54’s SBP was below 110 mmHg. LVN 4 stated the licensed nurses should not have followed the physician’s order to hold the medication when the SBP was less than 110 mmHg. 2. A review of Resident 36's Admission Record indicated the facility admitted the resident on 6/10/2016 and readmitted the resident on 1/14/2022 with diagnoses including hypertensive heart with heart failure (a condition that develops when your heart does not pump enough blood for the body's needs). A review of Resident 36 Physician’s Order, dated 8/2/2023, indicated to administer the resident carvedilol 3.125 mg twice a day for hypertension and hold it if SBP less than 120 mmHg or the HR less than 60 bmp. On 10/3/2023 at 3:52 p.m., during a concurrent interview with LVN 4 and a review of Resident 36's MAR for the month of 9/2023 indicated Resident 36 was administered carvedilol on 9/7/2023 and 9/12/2023 at 9 a.m., when Resident 54’s SBP was below 120 mmHg. LVN 4 stated the licensed nurses should not have followed the physician’s order to hold the medication when the SBP was less than 120 mmHg. 3. A review of Resident 52`s Admission Record indicated the resident was originally admitted to the facility on 06/19/2018 and readmitted on 2/4/2020, with diagnoses including heart failure. A review of Resident 52 Physician’s Order, dated 4/23/2021, indicated to administer the resident metoprolol tartrate 75 mg twice a day for hypertension and hold if the SBP less than 100 mmHg and HR less than 60 bpm. On 10/3/2023 at 3:52 p.m., during a concurrent interview with LVN 4 and a review of Resident 52's MAR for the month of 9/2023 indicated Resident 52 was administered metoprolol on 9/10/2023 and 9/16/2023 at 5 p.m. and 9 a.m. respectively, when Resident 52’s SBP was below 100 mmHg. LVN 4 stated the licensed nurses should not have followed the physician’s order to hold the medication when the SBP was less than 100 mmHg. 4. A review of Resident 49's Admission Record indicated the facility originally admitted the resident on 7/15/2022 and re-admitted the resident on 2/11/2023 with diagnoses including hypertension and atherosclerotic heart disease (hardening on the heart arteries which can cause chest pain). A review of Resident 49's Physician's Order, dated 2/11/2023, indicated to administer the resident amiodarone 200 mg once daily for coronary artery disease (CAD, hardening of the heart arteries which can cause chest pain), hold if HR less than 60 bmp. A review of Resident 49's Physician's Order, dated 3/9/2023, indicated to administer the resident isosorbide mononitrate extended release (released in the body over 24 hours) 60 mg in the morning to prevent chest pain, hold if SBP less than110 mmHg and the HR less than 55 bpm. A review of Resident 49's MAR for the months of 8/2023 and 9/2023 indicated on 8/24/2023, 9/5/2023, and 9/19/2023, amiodarone was given when the resident’s HR was below 60 bpm. A review of Resident 49’s MAR from 3/2023 to 9/2023 indicated there were 42 instances when isosorbide mononitrate was held when Resident 49's HR and SBP were not as per the physician’s parameter to hold the medication. On 10/05/2023 at 2:50 p.m., during an interview, the Director of Nursing (DON) stated Resident 49's isosorbide was to be held only if both the resident's HR was less than 55 bmp and SBP was less than 110 mmHg. The DON stated the licensed nursing did not follow the physician's order each time Resident 49's isosorbide was held when the resident's SBP was greater than 110 mmHg, but the resident's HR was 55 bmp or less. On 10/05/2023 at 3:52 p.m., during an interview, Resident 49's attending physician stated for Resident 49's isosorbide, both parameters (the SBP and the HR) should be below the specified parameters to hold the medication. 5. A review of Resident 47's Admission Record indicated the resident was originally admitted on 9/21/2020, with diagnoses including failure and atrial fibrillation (irregular heart rate) A review of Resident 47 Physician’s Order, dated 8/20/2022, indicated to give the resident amiodarone 100 mg daily for atrial fibrillation and hold it if the HR was below 60 bmp. A review of Resident 47's MAR for 9/2023 indicated that on 9/17/2023 at 9:00 a.m., Resident 47's HR was 58 bmp and amiodarone was administered. 6. A review of Resident 2's Admission Record indicated the facility admitted the resident on 7/11/2006 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 2 Physician’s Order, dated 6/4/2019, indicated to administer the resident Admelog six units subcutaneous injection (under the skin) before meals and hold if the BS was below 100 mg/dL. On 10/4/2023 at 8:06 a.m., during an interview with Registered Nurse 2 (RN 2) and concurrent review of Resident 2's MAR for the month of 9/2023 indicated that on 9/7/2023 twice and once on 9/15/2023, 9/17/2023, 9/22/2023, and 9/29,2023 Resident 2 was administered Admelog when the BS was below 100 mg/dL. RN 2 stated Admelog should not have been administered to Resident 2 when the BS was below the parameter because it could have caused further drop of Resident 2's BS that could lead to unresponsiveness. On 10/4/2023 at 1:10 p.m. during an interview, the DON stated all medications are to be administered in accordance with physician's orders. A review of the facility policy and procedure titled, "Medication Administration - General Guidelines," last reviewed 1/26/2023, indicated medications are administered in accordance with written orders of the attending physician. The facility failed to ensure Residents 54, 36, 52, 49, 47, and 2 were free from significant medication error by not ensuring: 1. Amlodipine besylate was administered in accordance with the physician's order with a parameter to hold the medication if Resident 54's SBP was less than 110 mmHg. 2. Carvedilol was administered in accordance with the physician's order with a parameter to hold if Resident 36's SBP was less than 120 mmHg. 3. Metoprolol tartrate was administered in accordance with the physician's order with a parameter to hold if Resident 52's SBP was less than 100 mmHg and the HR was less than 60 bpm. 4. Amiodarone was administered in accordance with the physician's order with a parameter to hold if Resident 49’s HR was less than 60 bmp and that isosorbide mononitrate was held if the SBP was less than110 mmHg and the HR less than 55 bpm. 5. Amiodarone was administered in accordance with the physician's order with a parameter to hold if Resident 47’s HR was less than 60 bmp. 6. Admelog was administered to Resident 2 in accordance with the physician's order to hold the medication if the residents BS was below 100 mg/dL. As a result, Residents 54, 36, 52, 49, and 47 were placed at risk for hypotension which could lead to dizziness, headache, fainting, blurred vision, shallow breathing, and injury from falls and Resident 2 was placed at risk for experiencing hypoglycemia which may result in confusion, heart palpitations, shakiness, and anxiety. The above violations had a direct relationship to the health, safety, or security of Residents 54, 36, 52, 49, 47, and 2.