Health inspection·July 25, 2024

CFR §483.45 Pharmacy Services (e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; (e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and CCR 22 § 72319 - Nursing Service-Restraints and Postural Supports (a)Written policies and procedures concerning the use of restraints and postural supports shall be followed (j) When drugs are used to restrain or control behavior or to treat a disordered thought process, the following shall apply: (1) The specific behavior or manifestation of disordered thought process to be treated with the drug is identified in the patient's health record. (2) The plan of care for each patient specifies data to be collected for use in evaluating the effectiveness of the drugs and the occurrence of adverse reactions. (3) The data collected shall be made available to the prescriber in a consolidated manner at least monthly. (4) PRN orders for such drugs shall be subject to the requirements of this section. CCR 22 §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. The California Department of Public Health (CDPH) conducted a recertification survey on 6/4/2024 - 6/11/2024. During the recertification survey during observation, interview, and record review CDPH identified the facility failed to: 1. Ensure Resident 6 did not receive routine and as needed Sertraline and Ativan unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 6. 2. Ensure Resident 22 did not receive routine Ativan and Seroquel as needed unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 22. 3. Ensure Resident 34 did not receive Risperdal and Ativan without indication for use for one month from 5/9/2024 to 6/11/2024. These deficient practices resulted in: 1. Placing Resident 6 at high risk for Sertraline adverse effects including confusion, diarrhea, and headaches, and Ativan adverse effects including confusion, blurred vision, dizziness, and drowsiness. 2. Placing Resident 22 at high risk for adverse effects of Ativan including confusion, blurred vision, dizziness and drowsiness and Seroquel adverse effects including dizziness, headache, and high blood sugar. 3. Resident 34 to be at high risk for adverse effects of the Respiradol and Ativan medications such as blurred vision, dizziness, tremors, stiffness, agitation, and heart rhythm irregularities. 3. A review of Resident 6's Admission Record, indicated Resident 6 a 94-year-old female was initially admitted to the facility on 3/31/2019 and readmitted on 4/3/2024 with diagnoses including recurrent major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia and Alzheimer's disease. 1. A review of Resident 6's H&P dated 4/12/2024, indicated Resident 6 had fluctuating capacity to understand and make decisions. A review of Resident 6's MDS dated 2/29/2024, indicated Resident 6 required maximal assistance from one staff for toilet hygiene, shower, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, and moderate assistance from one staff for oral hygiene. The MDS indicated, eating was not attempted due to medical condition or safety concerns. The MDS indicated, Resident 6 did not have hallucination or delusions and did not reject care. A review of Resident 6's Preadmission Screening and Resident Review ([PASARR]- Screening to evaluate if a resident needs additional supportive services) level I dated 8/10/2023, indicated a positive level I screening which indicates a level II mental health evaluation was required. A review of Resident 6's PASARR level II, dated on 8/10/2023 indicated, "unable to complete level II evaluation. The individual has no serious mental illness." A review of Resident 6's care plan, initiated on 3/20/2023 and revised on 6/4/2024 indicated, Resident 6 was receiving Ativan due to anxiety manifested by verbalization of feeling anxious. The care plan interventions included to administer antianxiety medication as ordered by the physician and monitor for side effects. A review of Resident 6's care plan indicated Resident 6 was receiving Sertraline (antidepressant medication) for depression manifested by verbalization of sadness. The care plan interventions included to administer antidepressant medication as ordered by the physician and monitor for side effects. A review of Resident 6's Physician's Order Summary Report, dated 6/6/2024, indicated a physician's order dated 5/2/2024 to monitor the resident for depression and tally (document for each occurrence) episodes of depression every shift for Sertraline use. The Physician's Order Summary Report indicated a physician's order, dated 5/2/2024, to monitor Resident 6 for anxiety and tally episodes of anxiety every shift for Ativan use. A review of Resident 6's Physician's Order Summary Report, dated 6/6/2024, indicated a physician's order, dated 5/10/2024 to monitor the resident for episodes of depression manifested by verbalization of feeling depressed and tally episodes every shift for Sertraline use. The Physician's Order Summary Report indicated a physician's order, dated 5/10/2024 to monitor the resident for episodes of anxiety manifested by verbalization of feeling anxious and tally number of episodes every shift for Ativan use. A review of Resident 6's MAR, dated 6/2024, indicated, a physician's order dated 6/4/2024 for Ativan 0.5mg, one tablet every 12 hours as needed for anxiety manifested by verbalization of feeling anxious. A review of Resident 6's MAR, dated 6/2024, indicated a physician's order for Sertraline 50 mg, one tablet at for depression manifested by verbalization of feeling depressed. During an interview on 6/6/2024, at 11:25 am, and concurrent record review with RNS 1, Resident 6's MAR, from 3/1/2024 to 6/4/2024 was reviewed. The MAR indicated, there was no documentation of the resident's anxiety and depression episodes under Behavior Monitoring sections. RNS 1 stated, GDR should have been attempted because there were no behavioral episodes documented on the MAR. The MAR indicated. A review of Resident 6's IDT Care Conference notes, dated 5/15/2024, indicated, GDR was contraindicated at this time because the resident was on an optimal dose and was clinically stable. During an interview on 6/7/2024, at 10:36 am, the DON stated the facility should have attempted GDR for Residents 6 based on the number of behavioral episodes. The DON stated Resident 6 had dementia and Alzheimer and staff should have considered and ruled out symptoms of those diagnoses before giving psychotropic medication. The DON stated, it would be considered as a chemical restraint when psychotropic medications were given unnecessarily, and its use should be minimized. During an interview on 6/10/2024, 2:30 pm, the PPA 1 stated GDR should have been attempted if the resident did not have any behavioral episodes or a reasonable number of episodes such as two or three episodes per month, to prevent giving psychotropic medications to the residents excessively. The PPA 1 stated the goal was giving psychotropic medication as little as possible to control the behavior. The PPA 1 stated behaviors due psychosis were similar to behaviors due to dementia and Alzheimer disease. The PPA 1 stated healthcare practitioners should rule out those diagnoses before medicating residents for psychosis with psychotropic medication, to avoid prescribing residents unnecessary medications. The PPA 1 stated residents could suffer from adverse reaction and side effects of the psychotropic medications. 2. A review of Resident 22's Admission Record indicated Resident 22 was admitted to the facility on 5/7/2024 with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), dementia and Alzheimer's disease. A review of Resident 22's H&P dated 5/10/2024 indicated, Resident 22 had no capacity to understand and make decisions. A review of Resident 22's MDS, dated 5/13/2024, indicated Resident 22 required assistance from two or more staff for shower, toileting hygiene, personal hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, moderate assistance from one staff for eating, oral hygiene, and independent for rolling left and right. The MDS indicated Resident 22 was taking medications. The MDS indicated Resident 22 had no hallucinations or delusions and no physical, verbal, or other behavioral symptoms. The MDS indicated, Resident 22 had no behavior of rejecting care or wandering. During a review of Resident 22's PASSAR dated 5/7/2024, indicated Negative level I (assessment determined the resident does not need additional services) and a level II mental evaluation was not required. A review of Resident 22's untitled Care Plan, initiated on 5/11/2024, indicated Resident 22 was receiving Seroquel, a psychotropic medication Seroquel for the behavior management. The care plan interventions included to administer psychotropic medication as ordered and to monitor for medication side effects. A review of Resident 22's untitled Care Plan initiated on 5/11/2024, indicated Resident 22 receiving Ativan, a psychotropic medication for anxiety. The Care Plan interventions included to administer antianxiety medication as ordered by physician and monitor for medication side effects. A review of Resident 22's Physician's Order Summary Report, dated 6/6/2024, indicated the following physician's orders: a. an order dated 5/7/2024 for Ativan 0.5 mg one tablet every six hours as needed for anxiety manifested by agitation. b. An order dated 5/7/2024 and renewed on 5/27/2024 for Seroquel 25 mg in 24 hours as needed for anxiety manifested by restlessness. c. An order dated 6/1/2024 to monitor Resident 22 for episodes of anxiety manifested by restlessness, tally by hashmark every shift. A review of Resident 22's MAR dated from 5/7/2024 to 6/4/2024 indicated Resident 22 was hashmark for Seroquel 25 mg daily use for restlessness on 6/1/2024 at 4pm and on 6/3/2024 at 4 pm The MAR indicated Resident 22 received Seroquel 25 mg daily eight times between 5/27/2024 through 6/3/2024. Resident 22 received the Seroquel as follows: a. On 5/27/2024 at 3 pm b. On 5/27/2024 at 3 pm c. On 5/28/2024 at 3 pm d. On 5/29/2024 at 3 pm e. On 5/30/2024 at 4 pm f. On 5/31/2024 at 4 pm g. On 6/1/2024 at 4 pm h. On 6/2/2024 at 4 pm i. On 6/3/2024 at 4 pm A review of Resident 22's Physician's Order dated 6/5/2024 indicated, Seroquel 50 mg two times a day for psychosis m/b aggression and combativeness. A review of Resident 22's MAR dated 6/5/2024 indicated Resident 22 had no behavioral episodes of restlessness to warrant administration of Seroquel 50 mg, two times a day for psychosis manifested by aggression and combativeness. The MAR indicated Resident 22 refused Seroquel on 6/5/2024 at 5:00 pm and on 6/6/2024 at 5:00 pm. The MAR indicated Resident 22 received Seroquel on 6/6/2024, at 9:00 a.m. A review of Resident 22's MAR dated from 5/7/2024 to 6/4/2024 indicated Resident 22 was given Ativan 0.5 mg seven times between 5/7/2024 and 5/31/2024. Resident 22 received Ativan 0.5 mg on 5/7/2024 at 8:46 pm, on 5/15/2024 at 3:55 pm, on 5/16/2024 at 7:33 pm, on 5/25/2024 at 6:27 pm, on 5/26/2024 at 4:03pm, on 5/30/2024 at 8:32 p, and on 5/31/2024 at9:33 pm. It was documented on MAR the medication was effective. A review of Resident 22's Hospice RN 2 Visit Note dated 6/4/2024 indicated per staff Resident 22 had behavioral issues at night and staff reported that Ativan was not effective to calm the resident down. The Hospice RN Visit Note indicated the physician gave a new order for Seroquel 50 mg twice a day for psychosis received. (Seroquel dose was increased four times from 25 mg once a day to 50 mg twice a day [total of 100 mg daily]). A review of Resident 22's Hospice RN Visit Note dated 6/7/2024 indicated Resident 22 had no anxiety, depression, or agitation. The Hospice RN Visit Note indicated the facility's staff reported Resident 22 was still having a lot of behavioral issues, especially during bathing and incontinence brief changes, not allowing staff to adequately clean her. The Hospice RN visit note indicated the facility's staff reported Resident 22 was very agitated at night, attempted to get out of bed and called out for her family and was confused. A review of Resident 22's IDT Care Conference Notes dated 5/10/2024 and signed on 5/16/2024 indicated GDR was discussed. The IDT Care Conference Notes indicated there were no behaviors noted at this time in Resident 22's Behavior Problem/Psychotropic Medication section. During an interview on 6/6/2024, at 11:15 pm, RNS 1 stated Resident 22 did not have many behavioral episodes and there was no reason to increase the dose for Seroquel from 25 mg to 50 mg. RNS 1 stated staff should have documented the number of behavioral episodes instead of documenting 'yes' or 'No.' RNS 1 stated, Resident 22's irritation and aggression could be signs and symptoms of her diagnosis of dementia and Alzheimer's disease. During an interview on 6/7/2024, at 10:45 am, the DON stated the facility should have attempted GDR for Resident 6 based on the number of behavioral episodes. The DON stated Resident 6 had dementia and Alzheimer and staff should have considered and ruled out symptoms of those diagnoses before giving psychotropic medication. The DON stated, it would be considered as a chemical restraint when psychotropic medications were given unnecessarily, and its use should be minimized. 3. A review of Resident 34's Admission Record indicated Resident 34 an 84-year-old female was admitted to the facility on 5/8/2024, with diagnoses including dementia without behavioral disturbances, psychotic disturbances (severe mental disorder that causes abnormal thinking and perceptions), mood disturbances (mood disorders that affect a person's emotional state and quality of life) and anxiety (an intense excessive and persistent worry and fear about everyday situations). A review of Resident 34's Progress Notes, dated 5/8/2024, indicated Resident 34 was admitted to the facility with diagnoses including weakness, hypertension and rule out dementia. The Progress Note indicated Resident 34 was alert and oriented to name, place, and time and was able to make needs known. The Progress Notes indicated Resident 34 was pleasant upon approach, had a pleasant mood, and no unwanted behavior was witnessed. The Progress Notes indicated Resident 34's speech was clear, and the resident was able to understand and was understood when speaking. A review of Resident 34's H&P dated 5/9/2024, indicated Resident 34 had the capacity to understand and make decisions. A review of Resident 34's Progress Notes dated 5/9/2024 indicated Resident 34 had no psychiatric problems. The Progress Notes indicated Resident 34 became angry and hostile after finding out she was in a nursing home. The Progress Notes indicated Ativan one mg was offered to Resident 34, but the resident refused Ativan stating, "You are trying to kill me"