Health inspection·May 24, 2024

Amended 6/3/24 HSC §1424 (f) (2)"Willful material falsification," as used in this section, means any entry in the patient health care record pertaining to the administration of medication, or treatments ordered for the patient, or pertaining to services for the prevention or treatment of decubitus ulcers or contractures, or pertaining to test and measurements of vital signs, or notations of input and output of fluids, that was made with the knowledge that the records falsely reflect the condition of the resident or the care or services provided.. HSC §1424.5 (a) In lieu of the fines specified in subdivisions (c), (d), (e), and (g) of Section 1424, fines imposed on skilled nursing facilities or intermediate care facilities, as specified in paragraphs (1) and (2) of subdivision (a) of Section 1418, shall be as follows (3) Any “willful material falsification” or “willful material omission,” as those terms are defined in subdivision (f) of Section 1424, in the health record of a resident is subject to a civil penalty in an amount not less than three thousand five hundred dollars ($3,500) and not exceeding twenty-five thousand dollars ($25,000) for each citation 22 CCR § 72543 Patient’s Health Records (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the health record shall be authenticated with the date, name, and title of the persons making the entry. 42 CFR § 483.70 – Administration (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are— (i) Complete (ii) Accurately documented On 4/9/2024, the California Department of Public Health (CDPH) conducted a standard recertification survey. During the recertification survey CDPH identified that the facility failed to: 1. Ensure Resident 532’s MAR was not falsified by documenting that Symbicort (a medication used to treat breathing problems) that was unavailable in the facility, was administered to Resident 532 eight times between 4/1/2024 and 4/10/2024 2. Ensure Resident 532’s MAR was not falsified by documenting that Preservision AREDS2 vitamins (a vitamin supplement for the eyes) that were unavailable in the facility, were administered to Resident 532 18 times between 4/1/2024 and 4/9/202. The deficient practice of falsifying Resident 532’s medical record to indicate medications were administered when they were unavailable in the facility for administration placed Resident 532 at increased risk for experiencing worsening of asthma (a breathing condition characterized by life-threatening inflammation and constriction of the airway) or vision resulting in possible hospitalization or death A review of Resident 532’ an 88-year-old male’s Admission Record (a document containing a resident demographic and diagnostic information), dated 4/10/2024, indicated the resident was admitted to the facility on 3/28/2024 with diagnoses including asthma and macular degeneration (an eye disease that causes vision loss). A review of Resident 532’s History and Physical ([H&P] – a record of a comprehensive physician’s assessment), dated 4/1/2024, indicated the resident was unable to make his own medical decisions. A review of Resident 532’s MAR for April 2024, indicated Symbicort 160-4.5 micrograms ([mcg] – a unit of measure for mass) inhaler (a portable device for administering a drug which is to be breathed- in) was scheduled to be given every day at 9:00 AM starting on 4/1/2024 and Preservision AREDS2 vitamin tablets were scheduled to be given twice daily at 9:00 AM and 5:00 PM. During an observation and concurrent interview on 4/10/2024 at 9:43 AM, the licensed vocational nurse (LVN 8) was observed preparing the following medications for Resident 532: 1. Pro-Source (a protein supplement) 30 milliliters ([ml]- a unit of measure for volume). 2. Acidophilus (a probiotic supplement) one capsule 3. Aspirin 81 mg chewable tablet (a medication used to prevent blood clots). 4. Lisinopril 10 mg tablet (a medication used to treat high blood pressure). 5. Gabapentin 300 mg capsule (a medication used to treat pain). 6. Vitamin C liquid 5 ml (a vitamin supplement). 7. Zinc Sulfate 50 mg tablet (a supplement). 8. Eliquis 5 mg tablet (a medication used to prevent blood clots). LVN 8 stated Resident 532 has a gastrostomy tube ([GT] a soft tube surgically placed directly into the stomach for administration of nutrition and medication) and any medications which were not in liquid form would need to be crushed or opened and mixed with water before administration. During an interview on 4/10/2024 at 10:00 AM, LVN 8 stated Resident 532’s Symbicort inhaler was not available in the medication cart, and she would have to contact the pharmacy to order it. During an interview on 4/10/2024 at 10:05 AM, LVN 8 stated Resident 532’s Preservision AREDS2 vitamin tablets were not available in the medication cart, and she would have to contact the pharmacy to order them. During an observation on 4/10/2024 at 10:20 AM, LVN 8 was observed beginning the administration of the eight medications listed above one-by-one via Resident 532’s GT and at 10:29 AM, LVN 8 was observed completing the administration of all eight medications. LVN 8 was not observed administering any other medications for Resident 532 after this time. During an interview on 4/10/2024 at 10:32 AM, LVN 8 stated Resident 532's Preservision AREDS2 vitamins and Symbicort inhaler were unavailable in the medication cart or anywhere else in the facility so she would be unable to administer them that day, even though they were scheduled for him. A review of Resident 532’s MAR between 4/1/2024 and 4/10/2024 indicated Symbicort inhaler was administered a total of eight times at 9:00 AM on 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/9, and 4/10/2024, five of which were documented by LVN 8 on 4/4, 4/5, 4/6, 4/9 and 4/10/2024. A review of Resident 532’s MAR between 4/1/2024 and 4/9/2024 indicated Preservision AREDS2 vitamins were administered a total of 18 times, every day at 9:00 AM and 5:00 PM, four of which were documented by LVN 8 on 4/4, 4/5, 4/6, and 4/9/2024. During an interview on 4/10/2024 at 12:32 PM, LVN 8 stated Resident 532's Symbicort inhaler and Preservision AREDs2 vitamins had never been received from the pharmacy due to an issue with the cost of the medications. LVN 8 stated both medications were scheduled to start for Resident 532 on 4/1/2024 and currently, the facility has failed to resolve the issue with the pharmacy or follow-up with the physician to order an alternative. LVN 8 stated the checkmarks in the MAR with her initials between 4/1/2024 and 4/10/2024 indicated that a medication was successfully administered to a resident. LVN 8 stated she marked the MAR that Symbicort was administered five times at 9:00 AM on 4/4, 4/5, 4/6, 4/9, and 4/10/2024. LVN 8 stated she marked the MAR that Preservision AREDS2 vitamins were administered when they were not four times at 9:00 AM on 4/4, 4/5, 4/6, and 4/9/2024. LVN 8 stated due to her high workload she likely marked them in error because she checked off the resident's entire MAR at the end of the medication pass and did not check to see which medications were actually administered and which ones were not. LVN 8 stated if a medication is unavailable, it should not have a checkmark as administered in the MAR. LVN 8 stated if she is unable to complete a medication administration, the MAR should indicate it was not given with a corresponding documentation in the nurses' progress notes explaining the circumstances. LVN 8 stated not administering Resident 532's Symbicort for ten days increased the risk that Resident 532’s asthma could worsen possibly resulting in breathing issues requiring hospitalization. LVN 8 stated that marking the MAR that medications were administered when they were not created the risk that Resident 532's physician may increase the dosage on medications that falsely looked ineffective (due to Resident 532’s symptoms not improving due to lack of medication) increasing the risk that the resident may experience side effects related to their use, resulting in a decreased quality of life. During an interview on 4/10/2024 at 2:32 PM the Director of Nursing (DON) stated when a medication is unavailable to give, the LVN must notify the pharmacy, the resident’s physician, and let her (the DON) know about the missing medication as it would be treated as a medication error. The DON stated none of the LVNs contacted her about missing medications for Resident 532. The DON stated it was unacceptable to sign the MAR that medications were administered when they are not available in the building. The DON stated not administering medications or administering them late could result in medical complications that could possibly result in hospitalization. A review of the facility’s policy titled “Medication Administration,” dated 9/2/2022, indicated that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by a physician and in accordance with professional standards of practice. Medication can be administer within 60 minutes prior to or after scheduled time unless otherwise orders by a physician and sign MAR after medication was administered. A review of the facility’s policy titled “Documentation in Medical Record,” dated 9/2/2022, indicated each resident’s medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident’s progress. Principles of documentation include but are not limited to: documentation shall be factual, objective, and resident centered. False information shall not be documented.” The facility failed to: 1. Ensure Resident 532’s MAR was not falsified by documenting that Symbicort (a medication used to treat breathing problems) that was unavailable in the facility, was administered to Resident 532 eight times between 4/1/2024 and 4/10/2024 2. Ensure Resident 532’s MAR was not falsified by documenting that Preservision AREDS2 vitamins (a vitamin supplement for the eyes) that were unavailable in the facility, were administered to Resident 532 18 times between 4/1/2024 and 4/9/202. The deficient practice of falsifying Resident 532’s medical record to indicate medications were administered when they were unavailable in the facility for administration placed Resident 532 at increased risk for experiencing worsening of asthma or vision resulting in possible hospitalization or death. The above facts indicate there was a willful material falsification in the medical record for Resident 532.