Health inspection·August 11, 2023

42 CFR § 483.45(a) Pharmacy Services. The facility must ensure that - §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. 22 CCR § Section 72355 - Pharmaceutical Service - Requirements. (a) Pharmaceutical service shall include, but is not limited to, the following: (2) Dispensing of drugs and biologicals. (3) Monitoring the drug distribution system which includes ordering, dispensing and administering of medication. (B) Anti-infectives and drugs used to treat severe pain, nausea, agitation, diarrhea, or other severe discomfort shall be available and administered within four hours of the time ordered. (D) Refill of prescription drugs shall be available when needed. On 6/26/2023, the California Department of Public Health made an unannounced visit to the facility to conduct an annual Recertification Survey. During the Recertification survey, CDPH determined the facility failed to order medication refill for Xanax (medication used to treat anxiety and panic disorder) for Resident 29, to ensure there was a continued supply of medication between 6/22/2023 to 6/26/2023 for the resident not to miss any dose of prescribed medication Xanax. This deficient practice resulted in Resident 29 missing nine doses of Xanax medication and placed the resident at risk for anxiety exacerbation and diminished quality of life. A review of Resident 29's Admission Record indicated Resident 29 was admitted on 1/4/2018 with diagnoses including anxiety disorder (mental condition, symptoms include constant feelings of nervousness, panic, and fear), and major depressive disorder (an illness that negatively affects how one feels, thinks and acts). A review of Resident 29's Minimum Data Sheet [(MDS) a standardized assessment and care planning tool] dated 4/13/2023, indicated Resident 29's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making were intact. A review of Residents 29's Order Summary Report start dated 5/5/2023, indicated the physician’s order for Xanax (medication used to treat anxiety and panic disorder) one tablet 0.5 milligrams [(mg) a unit of measure of weight] by mouth every 12 hours related to anxiety disorder. During an interview on 6/26/2023 at 10:32 a.m., Resident 29 stated he did not get his antianxiety medication this morning and it had been over a couple of days since he got his Xanax which he needed for his anxiety. During an interview on 6/27/2023 at 3:53 p.m., Resident 29 stated, he still had not gotten his Xanax today, and he felt anxious. Resident 29 stated, he feels anxious, uncomfortable, and stressed out without the medication. Resident 29 stated, when he takes the medication, he feels calmer with less anxiety. Resident 29 stated, the medication nurses have not told him why they have not given him the medication when he asked for it. During a concurrent interview and record review on 6/28/2023 at 9:27 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 presented an empty bubble pack (medication containers that are blister cards with sealed compartments designed to help keep track of dosing) for Resident 29's Xanax, and confirmed, Resident 29's Xanax was not available for administration to the resident. LVN 1 stated, the night shift nurse endorsed to her that the night shift nurse sent the refill request to the pharmacy early this morning (6/28/2023). LVN 1 confirmed the last time Resident 29 received his Xanax was on 6/22/2023. LVN 1 stated, when a resident's medication is not available in the medication cart, the facility’s process is to assess the resident, to inform the physician (MD) that the resident had missed a dose of their ordered medication, and to call the pharmacy to request a refill. LVN 1 further stated, the nurses should reorder medications from the pharmacy about three days before the medication supply is exhausted. LVN 1 stated, when the resident does not get his antianxiety medication as prescribed, it would make the resident feel angry, anxious, stressed, and cause other negative emotions. During an interview on 6/28/2023 at 11:40 a.m., with Pharmacist (Pharm) 1, Pharm 1 stated that the last order from the facility for Resident 29’s Xanax 0.5 mg every 12 hours was received on 6/7/2023 and the medication was dispensed to the facility on 6/8/2023 at 4:34 a.m. Pharm 1 stated, there had been no requests for a refill since 6/7/2023. Pharm 1 stated, if a resident misses 9 doses of 0.5 mg Xanax for 5 days, the resident could experience anxiety exacerbation because the resident has not had any medication to relieve the anxiety. A review of Resident 29's Medication Administration Records (MAR) between 6/1/2023 through 6/26/2023, indicated Resident 29 had missed Xanax 0.5 mg on the following dates and times: 6/22/2023 at 9:00 p.m., 6/23/2023 at 9:00 a.m., 6/23/2023 at 9:00 p.m., 6/24/2023 at 9:00 a.m., 6/24/2023 at 9:00 p.m., 6/25/2023 at 9:00 a.m., 6/25/2023 at 9:00 p.m., 6/26/2023 at 9:00 a.m., 6/26/2023 at 9:00 p.m. During an interview on 6/29/2023 at 2:43 p.m., with Director of Nursing (DON), DON stated the facility's bubble pack has color coding which reminds nurses when to reorder the medication and medication should never run out. DON stated, if the resident is not receiving the antianxiety medication, it would affect the wellbeing of the resident including exacerbating resident's behavior. A review of the facility policy and procedure (P/P) titled, "Medication Administration" dated 12/19/2022, indicated medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards. A review of the facility policy and procedures (P/P) titled, "Medication Ordering and Receiving from Pharmacy," dated 4/2008, indicated to reorder medication five days in advance of need to assure an adequate supply is on hand. The P/P indicated to promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. The facility failed to: Order medication refill for Xanax for Resident 29, to ensure there was a continued supply of medication between 6/22/2023 to 6/26/2023 for the resident not to miss any dose of prescribed medication Xanax. This deficient practice resulted in Resident 29 missing nine doses of Xanax medication and placed the resident at risk for anxiety exacerbation and diminished quality of life. This violation had a direct or immediate relationship to the health, safety, or security of Resident 29.