Health inspection·July 23, 2025

§72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (4) To consent to or to refuse any treatment or procedure or participation in experimental research. §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. § 72528. Informed Consent Requirements (a) It is the responsibility of the attending licensed healthcare practitioner acting within the scope of his or her professional licensure to determine what information a reasonable person in the patient's condition and circumstances would consider material to a decision to accept or refuse a proposed treatment or procedure. Information that is commonly appreciated need not be disclosed. The disclosure of the material information and obtaining informed consent shall be the responsibility of the licensed healthcare practitioner who, acting within the scope of his or her professional licensure, performs or orders the procedure or treatment for which informed consent is required. On 6/11/2025, the California Department of Public Health (CDPH) conducted an unannounced relicensing survey at the facility. The facility failed to: 1. Obtain a written informed consent from Patient 401 and/or his responsible party (RP) prior to treatment of Aripiprazole (a psychotropic medication [medications that affects brain activities associated with mental processed and behavior]), Risperidone (a psychotropic medication), Trazodone (an antidepressant medication used to treat depression [-a mental health disorder]), and Escitalopram (an antidepressant medication). 2. Ensure Patient 403’s written informed consents for Olanzapine (an antipsychotic medication), Quetiapine fumarate (an antipsychotic medication), and Trazodone were complete. 3. Ensure Patient 403’s informed consent for Haldol (an antipsychotic medication) was obtained by the physician or advanced practice provider (APP, a healthcare professional who is not a physician but is authorized to perform many of the same medical tasks as a physician). These failures prevented Patients 401 and 403 from exercising their right to decline treatment of psychotropic medications and increased the risk of experiencing adverse effects leading to impairment or decline in their mental or physical condition or functional or psychosocial status. 1. Patient 401 was an 81-year-old male, originally admitted to the facility on 2/3/2025 and readmitted on 4/14/2025 with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and depression. A review of Patient 401’s Minimum Data Set ([MDS] – a resident assessment tool), dated 2/7/2025, indicated Patient 401’s cognitive skills for daily decision making was severely impaired. The MDS indicated Patient 401 required supervision from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Patient 401 received antipsychotic medication and antidepressant medication. A review of Patient 401’s Order Summary Report, dated 2/3/2025, indicated the following orders: 1. Aripiprazole 5 milligrams (mg), by mouth, once a day, for schizophrenia manifested (m/b) auditory hallucinations. 2. Risperidone 0.5 mg, by mouth, two times a day, for schizophrenia m/b paranoid delusions that others are out to get him. 3. Trazodone 50 mg, by mouth, at bedtime, for insomnia m/b inability to sleep. 4. Escitalopram 20 mg, by mouth, once a day, for depression m/b self-isolation. A review of Patient 401’s Medication Administration Record (MAR), dated 2/3/2025 through 2/28/2025, indicated Patient 401 was not administered Aripiprazole, Escitalopram, Risperidone, and Trazodone. During an interview on 6/11/2025 at 12:45 p.m., the Director of Nursing (DON) stated there was no documentation Patient 401 and/or his RP received education regarding the risks and benefits or informed consents were obtained for Aripiprazole, Risperidone, Trazodone, and Escitalopram prior to initiation on 2/3/2025. The DON stated as a result of uncompleted informed consent forms for Aripiprazole, Risperidone, Trazodone, and Escitalopram, Patient 401 and/or his RP were not given the opportunity to make an informed decision about whether to accept or refuse the prescribed medications. The DON stated Patient 401 and/or his RP should have been given the opportunity to make informed decisions regarding his care and treatment, as it was their right. The DON stated the licensed nurses were responsible for verifying informed consent was obtained by the physician and the written consent was placed in the patient’s clinical record. 2a. Patient 403 was a 64 year-old female originally admitted to the facility on 2/27/2025 and readmitted on 4/17/2025 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). A review of Patient 403’s General Acute Care Hospital (GACH) Discharge Instructions, dated 4/17/2025, indicated Patient 403 did not receive olanzapine, quetiapine fumarate, or trazodone while hospitalized nor did it indicate the resident was to receive the medications upon readmission to the facility. A review of Patient 403’s physician orders, dated 4/17/2025, indicated the following new orders: 1. Olanzapine 10 mg at bedtime. 2. Quetiapine fumarate 50 mg at bedtime. 3. Trazodone 50 mg at bedtime. A review of Patient 403’s records titled “Informed Consent for Use of Psychotropic Medication,” for the administration of olanzapine, quetiapine fumarate, and trazodone dated 4/18/2025, indicated informed consent was obtained by telephone from Patient 403’s RP (RP 1). The records did not indicate who provided the information, whether the resident or RP received the consent. The check box indicating that consent was being given for the proposed treatment was left blank. A review of Patient 403’s MAR dated 4/1/2025 to 4/30/2025 indicated Patient 403 received Olanzapine, Quetiapine, and Trazodone a total of 12 times. A review of Patient 403’s MAR dated 5/1/2025 to 4/31/2025 indicated Patient 403 received Olanzapine and Quetiapine a total of 28 times, and Trazodone a total of 30 times. A review of Patient 403’s MAR dated 6/1/2025 to 6/30/2025 indicated Patient 403 received Olanzapine, Quetiapine, and Trazodone a total of 11 times. During a concurrent interview and record review, on 6/12/2025 at 12:18 p.m., with the Director of Nursing (DON), Patient 403’s records titled “Informed Consent for Use of Psychotropic Medication,” dated 4/18/2025, were reviewed. The DON stated the records indicated informed consent was obtained for the administration of olanzapine, quetiapine, and trazodone. The DON stated the records did not indicate a physician or APP provided the information to RP 1 prior to the administration of the medications. The DON stated that the records indicated the check box for the statement of consent was not marked to clearly indicate informed consent was given by RP 1 for the administration of the medications. 2b. A review of Patient 403’s physician order, dated 5/11/2025, indicated Patient 403 was to receive Haldol 5 mg every six hours as needed, with no duration for administration specified. A review of Patient 403’s record titled “Informed Consent for Use of Psychotropic Medication,” for the administration of Haldol dated 5/11/2025, indicated Registered Nurse (RN) 1 provided the information and obtained informed consent from Family Member (FM) 1. The record did not indicate a physician or APP provided the material information to or obtained the informed consent from FM 1. During a concurrent interview and record review, on 6/12/2025 at 12:12 p.m., with the DON, Patient 403’s record titled “Informed Consent for Use of Psychotropic Medication,” dated 5/11/2025 was reviewed. The DON stated the record indicated RN 1 obtained informed consent from FM 1 for Haldol 5 mg every 6 hours as needed. The DON stated there was no duration specified of how long Patient 403 was to receive the medication. The DON further stated it was not within RN 1’s scope of practice to obtain informed consent. A review of Patient 403’s discontinued physician order, entered by Registered Nurse (RN) 1, dated 5/11/2025, indicated Patient 403 was to receive Haldol 5 mg one time only. A review of Patient 403’s progress note, dated 5/11/2025 at 8:54 a.m., indicated the facility was unable to reach RP 1 to obtain consent. The progress note indicated RN 1 spoke with FM 1 instead, and FM 1 gave consent for a one-time Haldol administration. A review of Patient 403’s record titled “Informed Consent for Use of Psychotropic Medication,” dated 5/11/2025, did not indicate a physician or APP provided the material information to FM 1 or RP 1 for the one-time administration of Haldol 5 mg. A review of Patient 403’s progress note, dated 5/11/2025 at 8:54 a.m., indicated Haldol 5 mg was administered via injection. During a concurrent interview and record review, on 6/12/2025 at 12:14 p.m., with the DON) Patient 403’s record titled “Informed Consent for Use of Psychotropic Medication,” dated 5/11/2025 was reviewed. The DON stated the record indicated informed consent for Haldol 5 mg was obtained from FM 1. The DON stated the record did not indicate a physician or APP provided the material information to FM 1 or RP 1 for the one-time administration of Haldol 5 mg. During an interview on 6/12/2025 at 9:54 a.m., with RP 1, RP 1 stated licensed nursing staff contacted her via telephone to inform her Patient 403 was to receive psychotropic medications. RP 1 stated the staff identified themselves over the telephone as nursing staff, and not as physicians or APPs. RP 1 stated she had not spoken to a physician or APP about Patient 403’s psychotropic medications, including the indications for the medications or their potential side effects. RP 1 stated she was also unaware the facility contacted FM 1 to obtain consent for the administration of Haldol. RP 1 stated she was responsible for making decisions related to Patient 403’s medical care and would have wanted to be informed of the medication being administered to determine if she consented to the treatment. During a concurrent interview and record review, on 6/12/2025 at 12:23 p.m., with the DON, the facility’s policy and procedure (P&P) titled “Verification of Informed Consent for Psychotherapeutic Medications,” revised 5/2024, was reviewed. The P&P indicated the physician was to obtain written informed consent and sign the informed consent documentation to declare that the required material information was provided. The DON stated the P&P indicated the probable duration of the medication was to be disclosed when obtaining informed consent. The DON stated the P&P indicated that prior to initiating treatment, staff were to verify that the patient’s health record contained informed consent with the required signatures. The DON stated it was important to verify informed consent was present to ensure the patient or RP was aware of the indication for the medication, and the potential side effects and complications. The DON stated the informed consent process was to ensure the patient or RP knew they had the right to decline the proposed treatment. A review of the facility's P&P titled “Psychotropic Medication Use,” revised 7/2022, the P&P indicated residents and/or the representative would be involved in the medication treatment. The P&P indicated the staff, and physician would review with the resident/representative the risk related to the medication. A review of the facility’s P&P titled “Verification of Informed Consent for Psychotherapeutic Medications,” revised 5/2024, the P&P indicated “Each resident has the right to be free from psychotherapeutic drugs and, to provide informed consent before treatment with psychotherapeutic drugs.” The P&P indicated the facility would obtain a written informed consent for treatment using psychotherapeutic drugs and signed written consent would be recorded in the resident’s medical record. A review of the facility’s P&P titled “Resident Rights,” undated, the P&P indicated all facility’s residents had the right to be informed of, and participate in, his or her treatment. The facility failed to: 1. Obtain a written informed consent from Patient 401 and/or his RP prior to treatment of Aripiprazole, Risperidone, Trazodone, and Escitalopram. 2. Ensure Patient 403’s written informed consents for Olanzapine, Quetiapine fumarate, and Trazodone were complete. 3. Ensure Patient 403’s informed consent for Haldol was obtained by the physician or APP. These failures prevented Patients 401 and 403 from exercising their right to decline treatment of psychotropic medications and increased the risk of experiencing adverse effects leading to impairment or decline in their mental or physical condition or functional or psychosocial status. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.