Health inspection·April 28, 2023

F605 §483.10(e) Respect and Dignity. The patient has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms, consistent with §483.12(a)(2). §483.12 The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the patient’s medical symptoms. §483.12(a) The facility must— §483.12(a)(2) Ensure that the patient is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the patient’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

F757 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) §483.45(d) Unnecessary Drugs—General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used— §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

F758 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. §483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that— §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; On 2/14/23 at 8:23 AM, an unannounced visit was made to the facility to investigate a complaint regarding patient’s quality of care and safety. The facility failed to ensure Patient 1, who had a diagnosis of Alzheimer’s disease (a progressive brain disease that affects memory, thinking and interferes with daily life), was free from chemical restraints (the intentional use of any medications to subdue, sedate, or restrain an individual) when the facility failed to determine the underlying cause of Patient 1’s increased agitation and monitor the adverse effects of four medications that affects the central nervous system (consists of the brain and spinal cord which controls thought, movement, and emotion, and breathing), received by the patient while residing at the facility. The facility did not follow their policy on “Psychotropic Drug Use” when the facility continued to administer all four medications in the presence of adverse reactions (undesired effect) which included confusion and respiratory depression (slows down breathing). As a result, Patient 1 experienced oxygen desaturation (low oxygen blood level) to 68% (normal range 90%-100%) and Patient 1 verbalized “she can’t breathe.” Patient 1 was transferred to the general acute care hospital (GACH). Findings: A review of an admission record indicated, Patient 1, an 84 year old female, was admitted to the facility on 12/27/22 and readmitted back to the facility on 1/9/23 with diagnoses that included acute kidney failure (failure of the kidney to filter out toxins and excess fluids in the body), Alzheimer’s disease (a progressive brain disease that affects memory, thinking and interferes with daily life), major depressive (a severe feeling of sadness and hopelessness) disorder, sick sinus syndrome ( abnormal heart rhythm ) with pacemaker (a metal device implanted into the heart to regulate the heart rate). A review of Patient 1’s History and Physical Examination, dated 12/28/22, indicated the patient had the capacity to understand and make decisions and was alert. A review of Patient 1’s care plan dated 12/28/22 indicated Patient 1 had the potential for mood problems related to admission and disease process. The care plan interventions indicated to prevent anxiety and depression, the facility would monitor and record mood and determine if problems seem to be related to external causes such as medications and report to physician. Further review of Patient 1’s care plan dated 12/28/22 indicated Patient 1 had potential for a psychosocial wellbeing problem related to loss of independence in relation to skilled nursing facility placement. The care plan interventions indicated the facility would identify precipitating factors and stressors and provide the opportunities for the family to participate in care. A review of Patient 1’s Physician’s Orders from the initial admission dated 12/27/22 indicated the following orders: 1. Venlafaxine Hydrochloride (a medication used to treat depression) 37.5 mg (milligrams, a unit of measurement) by mouth every day for depression manifested by verbalization of sadness. 2. Temazepam (medication used to treat insomnia [inability to fall asleep or remain asleep]) 15 mg tablet by mouth every 24 hours for insomnia given at bedtime. 3. Monitor for side effects of antidepressants that included sedation, drowsiness. 4. Monitor for side effects of antianxiety medications that included sedation, drowsiness, ataxia (poor muscle control that causes clumsy voluntary movements, difficulty with walking and balance), dizziness, confusion, falls, agitation, and mood swings. A review of Patient 1’s licensed nurse’s Progress Notes for Patient 1’s initial admission stay to the facility from 12/27/22 to 1/5/23 indicated on 12/30/22, timed at 4:19 PM, Patient 1 was alert forgetful, up in wheelchair and tolerated well, with tab alarm (an alarm attached to the chair/bed that alarms when a patient attempts to rise out from the chair) in bed and wheelchair to alert staff from patient getting up unassisted. On 12/31/22, timed at 1:22 PM, the Notes indicated Patient 1 was alert and oriented x 3 (name, person and time or date), without active symptoms or treatments affecting level of consciousness and cognition, mood, or behavior. On 1/5/23, at 7:28 PM, the Notes indicated Patient 1 was observed by a licensed nurse staring blankly and would regain consciousness after a second or two. On 1/5/23, at 10:25 PM, the Notes indicated Patient 1 was sent out to acute hospital via 911 (an emergency number) due to episodes of losing consciousness. A review of Patient 1’s readmission Physician Orders dated 1/9/23, indicated the following orders: On 1/10/23, timed 7:03 PM, an order was to administer Ativan (a medication used to treat anxiety [the fear of the unknown]) 0.5 mg tablet by mouth every six hours as needed for increased agitation. On 1/10/23, timed at 3:02 PM, an order was to administer Benadryl (medication to treat allergies of itching) 50 mg tablet by mouth every eight hours as needed for itching. On 1/10/23, timed at 7:33 PM, an order was to administer Temazepam capsule mg by mouth every 24 hours for insomnia. On 1/10/23, timed at 7:40 PM, the order indicated to monitor Patient 1 for side effects of antianxiety medications that included sedation, drowsiness, ataxia (poor muscle control that causes clumsy voluntary movements, difficulty with walking and balance), dizziness, confusion, falls, agitation, and mood swings. An order dated 1/19/23, timed at 3:02 PM, indicated a change in the order frequency of Benadryl 50 mg tablet by mouth from administering the medication 8 hours as needed for itching to administering the medication routinely twice a day for “pruritus (itchy skin).” An order dated 1/20/23, timed at 8:33 PM, indicated the Ativan order was increased from 0.5 mg to 1 mg by mouth every six hours as needed for increased agitation. A review of Patient 1’s readmission History and Physical Examination, dated 1/10/23, indicated Patient 1 could make needs known but could not make medical decisions. A review of Patient 1’s Medication Administration Record (MAR) for January 2023, indicated the patient was given Venlafaxine Hydrochloride 37.5 mg as scheduled at 9 AM every day from 1/1/23 to 1/22/23 for depression manifested by verbalization of sadness. Further review of the Patient 1’s MAR indicated the patient was given Ativan 0.5 mg tablet by mouth every six hours as needed for increased agitation on the following dates and times: On 1/11/23 at 3:45 AM, 9:49 AM, and 8:41 PM On 1/12/23 at 4:54 PM On 1/13/23 at 7:52 PM On 1/14/23 at 4:05 PM On 1/15/23 at 1:06 AM, 7:38 AM, and 6:16 PM On 1/16/23 at 3:02 AM and 9:26 PM On 1/17/23 at 1:00 AM and 7:35 AM On 1/18/23 at 2:42 AM, 9:04 AM, and 4:33 PM, and 10:23 PM On 1/19/23 at 7:24 AM, 3:25 PM, and at 4:40 PM On 1/20/23 at 8:41 AM and 7:36 PM A review of the MAR further indicated Ativan 1 mg was given to the patient by mouth every six hours as needed for increased agitation on the following dates and times: On 1/20/23 at 8:55 PM On 1/21/23 at 5:11 AM and 7:06 PM On1/23/23 at 12:15 AM A review of the MAR further indicated Benadryl 50 mg was given to the patient for itching on the following dates and times: On 1/18/23 at 2:30 AM and 6:23 PM On 1/19/23 at 2:21 AM and 5:36 PM On 1/20/23 at 6 AM and 5 PM On 1/21/23 at 6 AM and 5 PM On 1/22/23 at 6 AM and 5 PM Further review of the MAR indicated Temazepam 15 mg capsules were given to the patient on the following dates and time: On 1/10/23 at 10:50 PM On 1/11/23 at 11:02 PM On 1/13/23 at 10:25 PM On 1/14/23 at 10:40 PM On 1/17/23 at 12 AM On 1/18/23 at 7:32 PM On1/19/23 at 9:56 PM On 1/20/23 at 10:47 PM On 1/22/23 at 7:44 PM A review of Patient 1’s licensed nurse’s Progress Notes, for Patient 1’s readmission back to the facility from 1/9/23 to 1/23/23 indicated on 1/10/23, timed at 2:14 AM, Patient 1 was readmitted back to the facility from GACH 1 on 1/9/23 timed at 11:45 PM. The progress note indicated Patient 1 was on continuous oxygen at 2 liters per minute. A review of the Notes further indicated that on 1/11/23, timed at 2:18 AM, Patient 1 was sitting in the wheelchair and refused to go to bed. Patient 1 was wheeled to the Nursing Station. On 1/11/23 at 3:45 AM, Patient 1 received Ativan 0.5 mg tablet for increased agitation. The progress note did not indicate documented evidence of nonpharmacological interventions (Interventions used as a way to temporarily manage symptoms that can affect a person’s mood and behaviors) were provided to Patient 1 prior to the administering of Ativan to the patient. The Notes further indicated that on 1/11/23, timed at 11:54 AM, Patient 1 attempted to get out of bed unassisted and purposely slid down her wheelchair and was sitting on the footrest. Further review of Patient 1’s MAR indicated that on 1/11/23, Patient 1 received Ativan 0.5 mg given for increased agitation at 3:45 AM, 9:49 AM, and 8:41 PM. Patient 1 also received Venlafaxine Hydrochloride 37.5 mgs for depression manifested by verbalization of sadness at 9 AM and Temazepam 15 mg capsule for insomnia at 11:02 PM. The Notes indicated that on 1/13/23, timed at 4:30 PM, Patient 1 was constantly standing up from the wheelchair without asking for assistance. Patient 1 cannot say where she wants to go. Patient 1 has poor safety awareness and has no sense in direction. The progress note indicated the licensed nurse obtained new orders from the physician to apply a self-release belt when up in wheelchair. Further review of Patient 1’s MAR indicated that on 1/13/23 at 7:52 PM, Patient 1 received Ativan 0.5 mg for increased agitation. The progress note did not indicate documented evidences of nonpharmacological interventions were provided to Patient 1 prior to the administration of Ativan and the application of the self-release belt. The MAR further indicated that on 1/19/2023, timed at 10 PM, Patient 1 was found on the floor with the head resting on the side of the bed with the wheelchair in front of her. Patient 1 was found naked from the waist down with the diaper on the floor next to her, when interviewed Patient 1 stated “She was trying to get back to into the bed.” The progress note indicated the physician was notified. Further review of Patient 1’s MAR indicated that on 1/19/23, Patient 1 received Ativan 0.5 mg given for increased agitation at 7:24 AM and 3:25 PM. Patient 1 also received Venlafaxine Hydrochloride 37.5 mgs at 9 AM for depression and Benadryl 50 mgs at 2:21 AM and 5:36 PM for itching. Lastly, Patient 1 received Temazepam 15 mg capsule for insomnia at 9:56 PM. Further review of Patient 1’s MAR indicated that on 1/21/23 Patient 1 received Ativan 1 mg given for increased agitation at 5:11 AM and 7:06 PM. Patient 1 also received Venlafaxine Hydrochloride 37.5 mgs at 9AM for depression, Benadryl 1/20/23 for pruritus at 6 AM and 5 PM, Ibuprofen 600 mgs tablet given for pain management at 4:44 PM, and Temazepam 15 mg capsule for insomnia at 9:56 PM. The MAR further indicated that on 1/22/23 at 7:55 PM, (11 minutes after given Temazepam) Patient 1 had increased agitation during the shift and was kept in front of the Nursing Station. Patient 1 rested about 2 hours total in shift, woke up and went back to bed to sleep. Patient 1 was heard having slight wheezing (an abnormal lung sound caused by blockage in the airway), oxygen saturation (a level of oxygen in the blood with normal range 90% to 100%) at 88%, after 10 minutes Patient 1’s oxygen saturation was 97% with oxygen received at 3 liters per minute via nasal cannula (a plastic tube inserted in the nares to deliver oxygen). The physician was informed of the change of condition at 8 PM. Further review of Patient 1’s MAR indicated that on 1/22/23 Patient 1 received Ativan 1 mg for increased agitation at 9:38 AM and 3:38 PM, Benadryl 50 mgs capsule for pruritus at 6 AM and 5 PM, Venlafaxine Hydrochloride 37.5 mgs tablet at 9AM for depression, and Temazepam 15 mg capsule for insomnia at 7:44 PM. The MAR indicated that on 1/23/23 at 12:35 AM, Patient 1’s oxygen saturation was 68% and increased to 75% after the administration of 15 liters per minute of oxygen delivered via non rebreathing mask (a mask used to deliver high concentration of oxygen). On 1/23/23 at 7:26 AM, the MAR indicated that at 12:35 AM on 1/23/23, Patient 1 was sitting on the wheelchair awake in front of the Nursing Station and said she wanted to go t