Health inspection·January 2, 2024

42 CFR§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following 22 CCR § 72313 Nursing Service--Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. 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 11/13/2023, the California Department of Public Health (CDPH) conducted an unannounced visit for an annual recertification survey. The facility failed to: 1. Follow its policy and procedure (P&P) titled “Physician Orders” which indicated, to provide care and services to a resident in accordance with physician orders. Resident 70 was administered Methadone (a powerful medication used for pain relief and treatment of drug addiction) 5 milligrams ([mg]- a unit of measurement) instead of 50 mg as ordered by the resident’s physician, for six days (9/8/2023 to 9/13/2023). 2. Ensure the correct dose of Resident 70’s Methadone 50 mg twice a day (BID) was transcribed per physician’s order. 3. Ensure the pharmacy delivered Resident 70’s Methadone on 11/8/2023 as ordered by the Physician. 4. Ensure staff documented the correct dose of methadone administered to Resident 70, on the resident’s Electronic Medication Administration Record ([eMAR] an electronic record of medications administered to a resident) and the facility’s Controlled Drug Administration Record. 5. Notify Resident 70’s Physician that Resident 70 was administered Methadone 5mg from 9/8/23 to 9/13/23, instead of 50 mg BID, as ordered, and that Resident 70 was experiencing withdrawal symptoms. These failures caused Resident 70 to experience severe pain, inability to sleep, shortness of breath and anxiety (intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 70’s Admission Record indicated Resident 70 was a 60 year-old male, who was initially admitted to the facility on 9/1/2023, and readmitted on 11/8/2023 with diagnoses that included fibroblastic disorders (tumors that affect connective tissue of the body), heart failure (condition in which the heart does not pump enough blood to meet the body’s needs), chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems) and anxiety. A review of Resident 70’s Minimum Data Set ([MDS] a comprehensive resident assessment and care-screening tool), dated 9/14/2023, indicated Resident 70’s cognition (ability to think and reason) was intact and Resident 70 required extensive assistance for bed mobility, transfers, getting dressed, toileting and performing personal hygiene. A review of Resident 70’s Care Plan, titled, “At risk for pain or discomfort related to diagnosis of necrotizing fasciitis (aggressive skin and soft tissue infections that cause death of the muscle and tissues of the body), osteomyelitis (inflammation or swelling that occurs in the bone), and polyneuropathy (simultaneous [at the same time] malfunction [not working] of the nerves throughout the body),” dated 9/2/2023, and revised on 9/14/2023, indicated the staff’s interventions included to administer pain medications as ordered, observe for pain and provide comfort. A review of Resident 70’s History and Physical (H&P), dated 10/24/2023, indicated Resident 70 had a diagnosis of “polysubstance abuse (the consumption of one or more illicit substances over a defined period or simultaneously) and on methadone.” A review of Resident 70’s Physician’s Orders, dated 11/8/2023, indicated Resident 70 was to receive Methadone 5mg ([mg]- unit of measurement) BID for a total of 10 mg a day, for chronic pain. A review of the Pharmacy Delivery Receipt, dated 11/14/2023 and timed 12:01 p.m., indicated the facility received 14 tablets of Methadone 5 mg on 11/14/2023. During an interview, on 11/14/2023, at 8:25 a.m., Resident 70 stated, “I feel anxious, and I did not sleep well. They (staff) gave me a pill. It did not work. If I don’t have my Methadone, I will feel terrible. Makes me feel angry.” During an interview, 11/15/2023, at 7:36 a.m., Resident 70 stated he had generalized pain rated at eight (severe) out of ten, on a pain scale of 1 to 10 (where 1 represents no pain, and 10 is worse pain). Resident 70 stated he was anxious, short of breath, and could not sleep well the night before. During an interview on 11/15/2023, at 9:28 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 70 did not receive the dose of Methadone on 11/14/2023 and 11/15/2023, because the medication was not available in the facility. During an interview on 11/15/2023, at 9:55 a.m., the Pharmacist in Charge (PIC), stated the last dose of Methadone 5 mg, was delivered to the facility on 11/14/2023 at 6:22 p.m., and it was the first dose of the Methadone 5 mg delivered to the facility in the month of November 2023. The PIC stated Resident 70 had previously been prescribed Methadone 50 mg BID. The PIC stated 70 tablets of Methadone 10 mg were delivered to the facility on 10/31/2023, and no doses had been taken from the facility’s emergency medication kit. During a concurrent interview and record review on 11/16/2023, at 11:30 a.m., with LVN 1, Resident 70’s eMAR, dated, 11/2023, was reviewed. The eMAR indicated from 11/9/2023 to 11/13/2023 at 9:00 a.m. and 5p.m., Resident 70 received Methadone 5 mg. The eMAR indicated on 11/9/2023 and 11/13/2023 at 9:00 a.m., LVN 1 administered Methadone 5 mg to Resident 70. LVN 1 stated on 11/9/23 and 11/13/23 Methadone 5 mg was unavailable in the facility. LVN 1 stated she documented in error on Resident 70’s eMAR that the resident received 5 mg of methadone. LVN 1 stated she (LVN 1) should have followed up with the pharmacy for Resident 70’s Methadone to be delivered. LVN 1 stated Resident 70 was without Methadone from 11/8/2023 to 11/13/2023 (a total of 6 days). LVN 1 also stated not administering the resident’s methadone caused Resident 70 to have uncontrolled pain and discomfort. During a concurrent interview and record review on 11/16/2023, at 12:50 p.m., with LVN 2, Resident 70’s eMAR, dated 11/10/2023, was reviewed. The eMAR indicated LVN 2 administered 5mg of Methadone on the morning of 11/10/2023, to Resident 70. LVN 2 stated Methadone 5mg was not available and she inaccurately documented the administration of Methadone 5 mg on Resident 70’s eMAR. LVN 2 stated on 11/10/2023, she was assigned a lot of residents and did not follow up with the pharmacy for Resident 70’s methadone. LVN 2 stated, if the eMAR was not accurate, and Resident 70 had not received his dose of Methadone, the resident would be in pain and the resident’s quality of life would be affected. During an interview on 11/16/2023, at 1:51 p.m. Registered Nurse (RN) 1, stated she made a mistake when transcribing Resident 70’s physician order for Methadone on 11/8/2023. RN 1 stated the physician ordered Methadone 50 mg BID, but she (RN 1) transcribed the order as Methadone 5 mg BID in Resident 70’s eMAR. RN 1 stated she had another admission within the same hour as Resident 70’s admission, she felt rushed, and did not check to see if the eMAR had the correct order. RN 1 stated she did not notice the transcription error until 11/14/2023, six days after Resident 70 had been admitted to the facility. RN 1 stated this mistake placed Resident 70 at risk for pain and withdrawal from Methadone. During a concurrent interview and record review on 11/16/2023, at 2:54 p.m., with the Director of Nursing (DON), the facility’s Controlled Drug Administration Record, dated 11/2023, Resident 70’s eMAR, dated 11/2023, and Resident 70’s Nursing Progress Notes, dated 11/2023, were reviewed. The DON stated the Controlled Drug Administration Record indicated on 11/8/2023 at 8:41 a.m., and on 11/9/2023 at 4:17 p.m., 5 tablets of Methadone 10mg, for a total of 50 mg, were withdrawn from the controlled drug supply. The DON stated the Controlled Drug Administration Record indicated there was no preparation (process of taking the medication out of the bubble pack [packs designed to hold and separate doses of medication]) documented on 11/8/2023 for the 5 p.m., and on 11/9/2023 for the 9 a.m. doses. The DON stated there was no documentation to indicate the 9 a.m. and 5 p.m. doses of Methadone were withdrawn from the drug supply on 11/10/2023, 11/11/2023, 11/12/2023, and 11/13/2023. The DON stated per the eMAR, Resident 70 received Methadone 5 mg, on following dates/times: 11/8/2023, no administration at 9 a.m. 11/8/2023, 1 tablet at 5 p.m. 11/9/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/10/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/11/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/12/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/13/2023, 1 tablet at 9:00 a.m. and 5 p.m. The DON stated Resident 70 did not receive methadone on 11/8/2023, at 9 a.m., and the entire day of 11/14/2023. The DON stated, Nursing Progress Notes indicated Resident 70 was admitted to the facility around 11:00 a.m. but did not indicate why Resident 70 was not given methadone on 11/14/2023.The DON stated RN 1 had transcribed Methadone 5 mg BID instead of Methadone 50 mg BID when Resident 70 was readmitted to the facility on 11/8/2023. The DON stated the licensed nurses administered the wrong dose of Methadone and failed to provide Resident 70 Methadone 50 mg BID as ordered by the physician. The DON stated these failures led to significant medication errors, caused Resident 70 to exhibit pain, withdrawal, and anxiety symptoms. The DON also stated, “all of these practices can affect the quality of care for our residents.” During an interview on 11/16/2023, at 4:25 p.m., the PIC stated the pharmacy had not delivered Methadone 5mg because the pharmacy was questioning the dose. The PIC stated he made multiple attempts to reach the prescribing physician, and waited until the pharmacy received a signature authorization before delivering Resident 70’s methadone to the facility on 11/14/2023. The PIC stated that the pharmacy questioned the medication order and held the medication because the 5 mg dose was significantly low. The PIC stated with a medication like methadone, the dose was supposed to be gradually lowered by the physician and not drastically from 50 mg to 5 mg. The PIC stated if a resident had been on a high dose of methadone for a long period and received a significantly lower dose, it could cause withdrawal symptoms. The PIC stated, “If the resident received subtherapeutic (less than the amount needed to be effective) doses of methadone, especially if it was prescribed for chronic pain, then the resident may have endured pain.” During an in interview on 11/17/2023, at 11:24 a.m., Resident 70’s Physician’s Assistant (PA) 1, stated Resident 70 had the potential to experience withdrawal symptoms including, agitation, night sweats, inability to sleep, and anxiety, after receiving subtherapeutic doses of Methadone. PA 1 stated he was not made aware that Resident 70 was given a lower dose of Methadone. PA 1 stated he was not aware Resident 70 was experiencing, pain and anxiety. PA 1 stated it was important for him (PA 1) to be notified of Resident 70’s methadone dosage change and the resident’s presenting symptoms for further evaluate and treatment. A review of the facility’s P&P titled, “Physician Orders” (undated), indicated the facility was to provide care and services to the resident in accordance with physician orders. A review of the facility’s P&P titled, “Controlled Substances,” dated 4/2019, indicated the facility was to ensure medication administration included the name, strength, and dose of the medication and the time of administration. A review of the facility’s P&P titled, “Documentation Principles” (undated), indicated the facility was to ensure staff maintained clinical records in a manner that would comply with licensing and certification governmental agency requirements and professional standards. The P&P indicated clinical entries must be “accurate, legible clear and timely (recorded within the required time period).” The facility failed to: 1. Follow its P&P titled “Physician Orders” which indicated, to provide care and services to a resident in accordance with physician orders. Resident 70 was administered Methadone 5mg instead of 50mg as ordered by the resident’s physician, for six days (9/8/2023 to 9/13/2023). 2. Ensure the correct dose of Resident 70’s Methadone 50 mg BID was transcribed per physician’s order. 3. Ensure the pharmacy delivered Resident 70’s Methadone on 11/8/2023 as ordered by the Physician. 4. Ensure staff documented the correct dose of methadone administered to Resident 70, on the resident’s eMAR and the facility’s Controlled Drug Administration Record. 5. Notify Resident 70’s Physician that Resident 70 was administered Methadone 5mg from 9/8/23 to 9/13/23, instead of 50 mg BID, as ordered, and that Resident 70 was experiencing withdrawal symptoms. These failures caused Resident 70 to experience severe pain, inability to sleep, shortness of breath and anxiety. These violations jointly, separately, or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.