Health inspection·September 27, 2023

F755 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. 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. 72353. Pharmaceutical Service--General. (a) Arrangements shall be made to assure that pharmaceutical services are available to provide patients with prescribed drugs and biologicals. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 8/9/2023, the California Department of Public Health (CDPH) received a complaint alleging suspected abuse and neglect of a resident (Resident 1). On 8/14/2023 an unannounced visit was made to the facility to investigate the complaint allegation. As a result of the investigation, the CDPH determined medication was not available and/or not administered to Resident 1, 2, 3 and 4 as prescribed by the physician. The facility failed to: 1. Ensure Seroquel [Quetiapine] a medication used to treat psychotic disorders [a mental disorder characterized by a disconnection from reality])150 mg [(mg) a unit of a dose measurement) prescribed to Resident 1 for behavioral management ordered on 7/20/2023, was delivered by the facility’s pharmacy within four hours per facility’s policy and procedure titled “Specific Medication Administration Procedures,” and not delivered on 7/30/2023, which was 10 days after the order for the medication was placed. 2. Ensure Prednisone 10 mg (a medication used to decrease inflammation), prescribed to Resident 2 for knee inflammation, was delivered to the facility by the facility’s pharmacy. 3. Ensure Empagliflozin 10 mg ([Jardiance] a medication used to improve glucose [blood sugar (b/s)] control in people with type 2 diabetes [(DM) a chronic condition which affects the way the body processes b/s]) prescribed to Resident 3 for DM, was delivered to the facility by the facility’s pharmacy. 4. Ensure Trulicity (a medication used to improve b/s in people with type 2 DM) 0.75 mg/0.5 milliliters ([ml] a unit of liquid measurement) prescribed to Resident 4 for DM management, was delivered to the facility by the facility’s pharmacy. 5. Ensure the licensed nurses did not document the administration of Seroquel, Prednisone, Empagliflozin and Dulaglutide to Residents 1, 2, 3 and 4 when those medications were not present in the facility. 6. Ensure licensed nurses verified receipt of medications ordered and followed-up with the pharmacy when medications were not available for administration to residents. 7. Ensure the facility had a system in place to determine if the facility received ordered medications and verify the pharmacy’s delivery of those medications timely. 8. Ensure the licensed nurses followed the facility’s policy and procedure (P/P) titled “Medication Ordering and Receiving from Pharmacy Provider,” and “Specific Medication Administration Procedures,” and inform the pharmacy of the need for prompt medication delivery and requested the delivery within four hours to prevent medication administration delay. These failures resulted in Residents 1, 2, 3 and 4 not receiving their prescribed medications and ineffective medication management. These deficient practices placed Residents 1 at risk for increased and/or uncontrolled behaviors which could affect the safety of other residents, staff, and visitors, had the potential for Resident 2’s right knee inflammation to go unresolved with pain, and placed Resident 3 and 4 at risk for hyperglycemia (high b/s), coma (state of prolonged unconsciousness, including lack of response from which it is impossible to rouse a person), and death. A review of Resident 1’s Care Plan (CP) dated 7/19/2023, indicated Resident 1 had a potential for mood problems related to depression and schizoaffective disorder. The CP’s goal indicated Resident 1 would have an improved mood state through review date of 8/15/2023. The CP’s interventions included to administer medications as ordered. A review of Resident 1’s CP dated 7/19/2023, indicated Resident 1 had behavior problems as evidenced by aggressive, combative behaviors with attempts to hit staff members related to his diagnosis of schizoaffective disorder. The CP’s goal indicated Resident 1 would have fewer episodes of aggressive, combative behaviors, decreased episodes of attempting to hit staff members and would have no evidence of behavior problems through the review date of 8/15/2023. The CP’s interventions included administering medications as ordered. A review of Resident 1’s nurses progress notes (NPN), dated 7/13/2023 and timed at 3:26 p.m., a Change of Condition ([COC] a document indicating a deterioration or improvement in a resident’s physical or behavioral health which may require a modification in the resident’s treatment) dated 7/14/2023 and timed at 6:35 a.m., and a NPN dated 7/20/2023 and timed at 4:30 p.m., indicated Resident 1 exhibited behaviors which included wiping feces on his body, kicking, slapping, making racial remarks to facility staff, irritability and being easily annoyed by staff. A review of Resident 1’s Order Summary Report ([OSR] physician’s orders), dated 7/20/2023 indicated a physician order for Seroquel 150 milligram [(mg) unit of dose measurement] twice a day (BID) for behavior management for administration at 9 a.m. and 5 p.m. A review of Resident 1’s Pharmacy Delivery Receipt dated 8/16/2023, indicated 186 tablets of Seroquel 150 mg were delivered to the facility for Resident 1 on 7/30/2023. A review of Resident 1’s MAR, dated 7/2023, indicated Seroquel 150 mg was administered to Resident 1 from 7/20/2023 to 7/29/2023 at 9 a.m., and/or 5 p.m. The MAR indicated there was documentation that Seroquel 150 mg was not available from the pharmacy on 7/21/2023, 7/23/2023, 7/28/2023, and 7/30/2023 for the 9 a.m., and/or 5 p.m., doses. The MAR indicated Resident 1 missed 20 doses of Seroquel from 7/20/2023 to 7/29/2023 due to the medication not being available at the facility. A review of Resident 1’s NPN, dated from 7/20/2023 to 7/31/2023, indicated there was no documentation by licensed nurses indicating the facility’s pharmacy was notified that Resident 1’s Seroquel 150 mg had not been delivered to the facility. During an interview on 8/17/2023 at 4:35 p.m., the Licensed Vocational Nurse 1 (LVN 1) acknowledged he documented Seroquel 150 mg as given to Resident 1 on 7/21/2023, 7/26/2023, 7/27/2023, and 7/28/2023, at 5 p.m. LVN 1 stated he was probably in a hurry and did not verify Seroquel was in the medication cart prior to documenting he administered it to Resident 1. LVN 1 stated it was hard to stay focused and pay attention during his medication pass because there were so many interruptions during his shift. During an interview on 8/18/2023 at 3:54 p.m., RN 2 stated on 7/30/2023 for the 9 a.m., Seroquel dose, she documented on the MAR that the medication was not available. RN 2 stated she did not call the pharmacy because she thought someone previously called regarding Resident 1’s missing Seroquel and thought it was going to be delivered. RN 2 stated she did not know Seroquel was available in the non-antibiotic (a medication used to treat bacterial infections) Emergency-Kit ([E-Kit] a small quantity of medications which can be dispensed when pharmacy services are not available). B. A review of Resident 2’s Admission Record (Face Sheet) indicated Resident 2 was admitted to the facility on 6/2/2023 with diagnosis including history of falling, difficulty in walking and displaced fracture (bone breaks into two or more parts) of the right femoral neck (region just below the hip joint [where two bones meet]). A review of Resident 2’s MDS, dated 8/3/2023, indicated Resident 2’s cognitive skills for daily decision-making were severely impaired and Resident 2 was usually understood by other and was usually able to understand others. A review of Resident 2’s History and Physical (H&P), dated 6/3/2023, indicated Resident 2 was able to make her own medical decisions. A review of Resident 2’s OSR, dated 7/6/2023 indicated a physician’s order for Prednisone 10 mg three times daily (TID) at 7:30 a.m., 12 noon and 5 p.m. for knee inflammation on 7/6/2023. The OSR indicated Prednisone was to be discontinued on 7/9/2023 at 11:59 p.m. A review of Resident 2’s Pharmacy Delivery Receipt dated 8/16/2023, indicated there was no documentation that Prednisone 10 mg was delivered to the facility for Resident 2. A review of Resident 2’s MAR, dated 7/2023, indicated Prednisone 150 mg was administered to Resident 1 from 7/7/2023 to 7/9/2023 at 12 p.m., and/or 5 p.m. The MAR indicated licensed nurses documented that Prednisone 10 mg was not available on 7/8/2023 and 7/9/2023 at 7:30 a.m., and/or 12 p.m. The MAR indicated Resident 2 received five doses of Prednisone from 7/7/2023 to 7/9/2023 when the medication was not available in the facility. Resident 2 subsequently missed a total of seven doses of Prednisone 10 mg. A review of the facility’s nonantibiotic E-Kit Binder dated 7/2023 indicated there was no documentation that Prednisone 10 mg was removed from the E-Kit to administer to Resident 2. A review of Resident 2’s NPN, dated 7/20/2023 to 7/29/2023, indicated there was no documentation by the licensed nurses that they followed up with the facility’s pharmacy regarding Resident 2’s Prednisone 10 mg order. During an interview on 8/16/2023 at 1:23 p.m., Resident 2 stated there were several days when she got a different number of pills when she received her medication. Some days she may get five pills, and some days she may get six pills. Resident 2 stated, she asked the licensed nurses to explain what the medications were that they were giving to her and why the number of pills were inconsistent, and they (the licensed nurses) were not able to explain. During an interview on 8/21/2023 at 2:21 p.m., LVN 2 acknowledged she documented Prednisone 10 mg as given to Resident 2 at 12 p.m., on 7/7/2023 and 7/12/2023 when she did not administer this medication to Resident 2. LVN 2 stated she thinks she was working too fast and documented the medication as given by accident. C. A review of Resident 3’s Admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on 3/28/2023 with diagnosis including type 2 DM and congestive heart failure ([CHF] a chronic condition in which the heart does not pump blood as well as it should). A review of Resident 3’s MDS, dated 7/14/2023, indicated Resident 3 made independent decisions that were reasonable and consistent. A review of Resident 3’s OSR dated 3/28/2023, indicated a physician’s order for Empagliflozin 10 mg once a day for DM. A review of the facility’s Pharmacy Consolidated Delivery Sheet dated 6/8/2023, indicated 14 tablets of Empagliflozin 10 mg was delivered to the facility for Resident 3 on 6/8/2023. Fourteen tablets of Empagliflozin 10 mg, if given as ordered, would have lasted until 6/22/2023. However, a review of Resident 3’s Pharmacy Delivery Receipt dated 8/16/2023, indicated there was no documentation that Empagliflozin 10 mg was delivered to the facility for Resident 3 after 6/8/2023. A review of Resident 3’s MAR, dated 6/2023, indicated Empagliflozin 10 mg was administered to Resident 3 daily from 6/23/2023 to 6/30/2023. A review of Resident 3’s MAR, dated 7/2023, indicated Empagliflozin 10 mg was administered to Resident 3 daily from 7/1/2023 to 7/4/2023, and from 7/7/2023 to 7/11/2023. The MAR indicated documentation by the licensed nurses that Empagliflozin 10 mg was not available from the pharmacy on 7/5/2023, 7/6/2023 and 7/12/2023. Also, the MAR indicated licensed nurses documented Resident 3 received 17 doses of Empagliflozin 10 mg from 6/23/2023 to 7/12/2023 when the medication was not available in the facility. Resident 3 subsequently missed a total of 19 doses of Empagliflozin 10 mg. A review of Resident 3’s NPN, dated 6/23/20232023 to 7/12/2023, indicated there was no documentation by the licensed nurses indicating they notified the pharmacy to order additional Empagliflozin 10 mg when the medication ran out. A review of Resident 3’s Grievance Resolution Form (GRF) dated 7/4/2023, indicated Resident 3 had concerns with his diabetes medication. The GRF indicated the summary of findings/conclusion and corrective actions sections were left blank. D. A review of Resident 4’s Admission Records (Face Sheet) indicated Resident 3 was admitted to the facility on 5/25/2023 with diagnosis including type 2 DM and acute kidney failure (a sudden episode of kidney failure or kidney damage which happens within a few hours or days). A review of Resident 4’s MDS, dated 5/31/2023, indicated Resident 4’s cognitive skills for daily decision-making were moderately impaired and Resident 4 was usually understood others and was usually understood by others. A review of Resident 4’s OSR dated 6/22/2023, indicated a physician’s order for Trulicity 0.75 mg/0.5 milliliters ([ml] a unit of liquid volume measurement) once a day, every Sunday at 9 a.m., for diabetes management. A review of the Pharmacy Delivery Sheet dated 6/23/2023, indicated one dose of Trulicity 0.75 mg/0.5 ml was delivered to the facility on 6/23/2023 at 2:02 a.m. A review of the facility’s Pharmacy Delivery Receipt dated 8/16/2023, indicated there was no documentation that Trulicity 0.75 mg/0.5 ml was delivered to the facility after 6/23/2023. A review of Resident 4’s MAR dated 6/2023, indicated Resident 4’s Trulicity 0.75 mg/0.5ml was not available from the pharmacy on 6/25/2023. A review of Resident 4’s MAR dated 7/2023, indicated Resident 4’s Trulicity 0.75 mg/0.5 ml was not available from the pharmacy on 7/2/2023 and 7/16/2023. A review of Resident 4’s NPN, dated 6/25/2023 to 7/16/2023 indicated there was no documentation by the licensed nurses that they notified the pharmacy to follow up on Resident 4’s Trulicity when it was not available for administration as prescribed. A review of Resident 4’s MAR for from 6/25/2023 to 7/16/2023 indicated Resident 4 missed three doses of Trulicity. During an interview on 8/14/2023 at 12:59 p.m., Resident 4 stated the facility previously had issues with the pharmacy not delivering his medications timely. A review of the facility’s Resident Council Minutes (RCM), dated 6/22/2023, indicated the resident’s concerns included medications not being refilled in a timely manner. The RCM indicated in-services were given to the licensed nurses regarding refilling medications. A review of the facility’s RCM, dated 7/20/2023, indicated residents were concerned because medications were not being refilled, were not available, and licensed nurses from the 3 p.m. to 11 p.m., shift were not able to find the resident’s medications. A review of the RCM and an interview on 8/17/2023 at 10:06 a.m., with the DON indicated there was