Other·February 22, 2024

§ 72313. Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (1) No medication or treatment shall be administered except on the order of a person lawfully authorized to give such order. (2) Medications and treatments shall be administered as prescribed. (4) Preparation of doses for more than one scheduled administration time shall not be permitted. § 72361. Pharmaceutical Service - Orders for Drugs. (a) No drugs shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illness. (b) All drug orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The name, quantity or specific duration of therapy, dosage and time or frequency of administration of the drug, and the route of administration if other than oral shall be specified. “P.R.N.” orders shall also include the indication for use of a drug. § 72369. Pharmaceutical Service -Controlled Drugs. (a) Drugs listed in Schedules II, III and IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall not be accessible to other than licensed nursing, pharmacy and medical personnel designated by the licensee. Drugs listed in Schedule II of the above Act shall be stored in a locked cabinet or a locked drawer separate from noncontrolled drugs unless they are supplied on a scheduled basis as part of a unit dose medication system. (b) Separate records of use shall be maintained on all Schedule II drugs. Such records shall be maintained accurately and shall include the name of the patient, the prescription number, the drug name, strength and dose administered, the date and time of administration and the signature of the person administering the drug. Such records shall be reconciled at least daily and shall be retained at least one year. If such drugs are supplied on a scheduled basis as part of a unit dose medication system, such records need not be maintained separately. (c) Drug records shall be maintained for drugs listed in Schedules III and IV of the above Act in such a way that the receipt and disposition of each dose of any such drug may be readily traced. Such records need not be separate from other medication records. On 1/8/24 at 8 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to conduct an annual recertification survey at the facility. During the survey the facility was determined to have failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of patients (Patient 1, 2, 3 and 4) by failing to: 1. Ensure the licensed staffs clarifies the physician orders for Percocet (Generic name- oxycodone/APAP-a pain medication) medication did not have an overlapping pain scale for Patient 1. 2. Ensure accurate account of the use of the discontinued controlled substances (medications with a high potential for abuse) for Patients 2 who was prescribed Zolpidem (a controlled substance used to treat sleep problems) and Resident 3 who was prescribed Methadone (a controlled substance used to relieve chronic pain and to manage and treat opioid use disorder) that was continued to be stored in the medication carts (Medication Cart 1A and Medication Cart 2C). 3. Ensure Xanax (a medication to treat anxiety [the fear of the unknown]) was documented on the “Controlled Substance Count Sheet” (form that is filled out each time a controlled substance [medications that are tightly controlled because of the abuse potential] when taken out of the medication cart and given to the Patient 4, and document in the Medication Administration Record (MAR) as given. As a result of these deficient practices Patient 1 had the potential to develop dependence with Oxycodone (an opioid or class of drugs associated with high potential for abuse), to have duplication of therapy, overdose and increased risk for adverse consequences such as respiratory depression (decreased ability to breath). Patient 2 and Patient 3 had the potential to be at risk for medication errors, misuse, drug loss, diversion, and accidental exposure to controlled substances to patients and staff. Patient 4 had the potential to receive double dose of Xanax or and result in drug diversion (illegal distribution or abuse of prescription drugs for their unintended purposes). 1. During a review of Patient 1's Admission Record, (a document containing demographic and diagnostic information), indicated the patient was originally admitted to the facility on 9/6/23 and readmitted on dated 1/11/2024, the admission record indicated the patient was admitted to the facility originally on 9/16/2023 with diagnoses including arthritis (inflammation of the joints), multiple sites, and difficulty in walking. During a review of Patient 1's Minimum Data Set (MDS-an assessment tool) dated 12/18/2023, the MDS indicated Patient 1 had moderate cognitive (thought process and ability to reason or make decisions) impairment, that required maximal assistance from staff with personal hygiene, dressing, showering and toilet use and personal hygiene. During a review of Patient 1's Order Summary Report (a physician orders), dated 11/30/2023 and 1/11/2024, indicated the following: a. An order, date 9/18/2023, indicate to administer Percocet (Generic name- oxycodone/APAP-a pain medication) 10/325 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for severe pain (7-10). NTE 3 gm in 24 hours. b. A physician order, dated 9/19/2023, indicated to administer Oxycodone (a controlled substance used to relieve moderate to severe pain) with 5 milligrams (mg) and 325 mg of acetaminophen (a non-controlled pain reliever), give 1 tablet by mouth every 4 hours as needed for moderate pain (4-10). Not to exceed (NTE) 3 grams (gm) in 24 hours." During a review of Patient 1's care plan, dated 9/16/2023, indicated the focus of risk for adverse reaction related to polypharmacy (situation where Patient receives five or more medications). During a review of Patient 1's Medication Administration Record (MAR, a written record of all medications given to a patient), indicated the physician ordered and Patient 1 received the following: Oxycodone/APAP 10/325 mg tablet indicated as needed for severe pain (Pain level 7-10). Patient 1 received Oxycodone/APAP 10-325 for pain level 6, which was outside the physician order parameters on following dates and times: 12/5/2023 at 12:27 PM 12/6/2023 at 7:57 AM, 12:15 PM and 5:06 PM 12/7/2023 at 4:02 PM, 8:15 PM 12/8/2023 at 8:39 AM and 4:00 PM 12/9/2023 at 1:31 PM 12/10/2023 at 9:24 AM, 12/11/2023 at 8:32 PM 12/12/2023 at 8:30 AM 12/13/2023 at 8:15 AM and 12:20 PM 12/18/2023 at 9:14 AM 1/1/2024 at 7:55 AM and 12:31 PM 1/3/2024 at 1:25 PM 1/8/2024 at 12:13 PM The physician ordered Resident 1 to receive Oxycodone/APAP 5/325 mg tablet as needed for moderate pain (Pain level 4-10). Patient 1 received Oxycodone/APAP 5-325 for pain level greater than or equal to 7, which was an overlapping pain level parameter with the order for Oxycodone/APAP 10/325 mg for severe pain (Pain level 7-10) on following dates and times: 12/1/2023 at 5:20 PM 12/2/2023 at 9:24 AM and 5:34 PM 12/3/2023 at 9:39 AM and 4:52 PM 12/4/2023 at 4:31 PM 12/14/2023 at 4:22 PM 12/15/2023 at 7:39 AM, 1:49 PM and 8:03 PM 12/16/2023 at 9:36 AM and 2:40 PM 12/17/2023 at 10:01 AM 12/20/2023 at 3:31 PM 12/22/2023 at 5:00 AM 12/25/2023 at 5:11 AM, 10:06 AM and 9:30 PM 12/2/2023 at 5:57 AM 12/28/2023 at 6:18 AM 12/29/2023 at 12:06 AM, 8:38 AM and 12:40 PM 12/31/2023 at 3:20 PM and 7:34 PM 1/2/2024 at 11:52 PM 1/4/2024 at 1:05 PM During an interview on 1/11/2024 at 2:10 PM, Patient 1 stated, he has pain in his kneecaps (bone in front of the knee joint) that usually hurt when he takes a wrong step. During an interview on 1/11/2024 at 2:30 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, "Percocet 10/325 mg is given for severe pain 7-10 and oxycodone/APAP 5/325 mg is given for moderate pain 4-10. If the pain level is at 8, he will ask for 10/325mg". LVN 2 stated, she will clarify orders with physician because it should state moderate pain 4-6. LVN 2 stated there is a risk that due to unclear pain scale, Patient 1 can go untreated for pain if given less pain medication and there is a risk that Patient 1 can get overdosed if given more than necessary medication. During a review of the facility's policy and procedure (P&P) titled, "Pain Management", dated 5/2019, the P&P indicated, "Patients are provided and receive the care and services needed according to established practice guidelines. Patient pain is assessed and managed by an Interdisciplinary Team (IDT-team of facility staff responsible in planning the care of the patients) who work together to achieve the highest practicable outcome. The IDT Plan will reflect the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated." 2. A review of Patient 2's Admission Record, indicated, Patient 2 was admitted to the facility on 12/3/2020 with diagnoses that included dementia (a progressive brain disorder that affects memory and thought process), anxiety (a fear of the unknown), and major depressive disorder (a feeling severe sadness and hopelessness). During a review of Patient 2's Order Summary Report (a document containing a summary of all active physician orders), dated 11/30/2023 to 1/11/2024, did not indicate any physician order for Ambien (Generic name - Zolpidem) 5 mg. During a review of Patient 2's Physician Order, conducted with the LVN 11 on 1/10/24 at 12:10 PM, indicated the physician discontinued Ambien Tablet 5 mg (Zolpidem Tartrate) to be given by mouth every 24 hours as needed for sleep aid on 3/7/2022 at 1:54 PM, a further review indicated the prescriber noted to discontinue Ambien due to "14 days are up." During a review of Patient 2's care plans, revised on 3/30/2022, indicated Resident 2’s inability to sleep related to insomnia was resolved. During a concurrent interview and record review on 1/10/2024 at 12:15 PM with LVN 8, bubble pack for Zolpidem 5 mg was in the medication cart with quantity of 24 tablets remaining, and the Controlled Drug Record indicated, Zolpidem 5 mg was charted six times during the months of 6/2023 and 7/2023 even after the medication was discontinued on 3/7/22. The charting dates and times on CDR were documented as follows: 6/27/2023 4:32 AM 6/29/2023 16:30 (4:30 PM) 7/9/2023 19:20 (7:20 PM) - Wasted. 7/9/2023 19:24 (7:24 PM) 7/10/2023 2100 (9:00 PM) 7/11/2023 2100 (9:00 PM) LVN 8 stated, medication card for Zolpidem 5 mg should have been removed from the medication cart as the medication has been discontinued by the physician. LVN 8 stated, discontinued medications are to be given to Director of Nursing (DON) as soon as the order was discontinued by a physician. LVN 8 stated, "I cannot answer this one why it wasn't removed". During a review of Patient 2's MAR from 6/2023 to 7/2023, indicated no documentation that Zolpidem was administered to Patient 2 on 6/27/2023, 6/29/203, 7/9/2023, 7/10/2023, or 7/11/2023. During an interview on 1/10/2024 at 3:02 PM with Assistant Director of Nursing (ADON), ADON stated, discontinued medications are given to DON or ADON if DON was not at the facility. ADON stated, if the medication was discontinued on a weekend, then medication was expected to be given to ADON or DON on Monday followed by the weekend. During an interview on 1/10/2024 at 3:20 PM, the DON stated, the staff was supposed to give the DON the discontinued controlled medications immediately or 72 hours after the medication was discontinued. The DON stated, the nurses should have given to me any controlled medications that was used within a few months. DON stated the risk of having a discontinued medication in the medication cart could result in misuse the medication or drug diversion. During a review of "RX 1 (Facility's initial dispensing pharmacy) - Authorization to dispense a Schedule III-V Controlled Substance", dated 4/28/2023, indicated, Zolpidem 5 mg order for Patient 2 was requested for a quantity of 30 pills with four refills. During a review of document, titled "RX 1", indicated a prescription number with Patient 2's name with status delivered on 4/29/2023 at 5PM. During a phone interview on 1/11/2024 at 4:45 PM with Registered Pharmacist (RPh) 1 at RX 1, RPh 1 stated RX 1 was a specialty pharmacy and the pharmacy do not have Patient 2's current record for Zolpidem 5 mg. RPh 1 stated RX 2 (facility's dispensing pharmacy after merged with RX 1) was where the prescription for Zolpidem was filled. During a phone interview on 1/11/2024 at 5:00 PM with RPh 2 at RX 2, RPh 2 stated, "there was merge between RX 1 and RX 2 and when the merge happened, RX 1 did not receive the medications ordered by the physician after the facility merged with RX 2." RPh 2 stated, "RX 2 has stopped servicing the facility on 12/3/23. During a phone interview on 1/11/2024 at 5:15 PM with Data Entry Supervisor (DE 2), DE 2 confirmed that there was no dispensing records for Patient 2's Zolpidem at RX 2. During a review of the facility's P&P titled, "Pharmacy Services, Physician Orders," dated 5/2019, the P&P indicated, "No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses." 3. During a review of Patient 3's Admission Record, (a document containing demographic and diagnostic information), dated 1/10/2024, the admission record indicated Patient 30 was admitted to the facility on 12/11/2023 with diagnosis that included chronic pain syndrome (when people have symptoms beyond pain alone, like depression and anxiety which interfere with their daily lives). During a concurrent observation and interview on 1/10/2024 at 11 AM, with Licensed Vocational Nurse (LVN) 2, of the Medication Cart 1A, Patient 3's bubble pack of Methadone 10 mg had quantity of 13 tablets remaining and the CDR indicated a quantity of 14 tablets remaining. CDR indicated last administration Methadone was on 1/9/2024 at 5PM. LVN 2 stated she was nervous and forgot to document on CDR on 1/10/2024 after one tablet of Methadone 10 mg was removed from the medication card and after Methadone was administered to Patient 3. LVN 2 stated CDR should match MAR and the EHR (Electronic Health Record) to ensure appropriate medication administration to the Patient 3. LVN 2 stated administration should be documented to account for drug and to prevent medication errors or duplicate administration by another nurse, that can put Patient 3 to be at risk for drug overdose and misuse. During a concurrent interview and record review on 1/10/2024 at 11:24 AM with LVN 2, EHR for Patient 3, dated 1/10/2024, LVN 2 reviewed the EHR. The EHR indicated Methadone HCl Oral Tablet 10 mg was scheduled for 9:00 AM on 1/10/2024, documented as administered on 1/10/2024 at 9:51 AM. MAR indicated with a check mark that Methadone 10 mg was administered by LVN 2 on 1/10/2024 at 9:00 AM. LVN 2 stated that the medication administration was recorded on the EHR, but she forgot to document on CDR. During a review of the facility's P&P titled, "Controlled Substance Storage- Medication Storage in the Facility," revised date January 2018, the P&P indicated, "The medication regimen of patients using medications that have such discrepancies are reviewed to assure the patient has received all medications as ordered and the goal of therapy was met. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Documentation Examples, Form 12: INDIVIDUAL PATIENT'S CONTROLLED SUBSTANCE RECORD." 3. During a review of Patient 4's Admission record indicated Patient 4 was admitted to the facility in 7/28/2020 with diagnoses including but not limited to the following: insomnia (inability to sleep), anemia (low levels of red blood cells in the blood), and rectal abscess (collection of pus that develops near the rectum). D