Health inspection·June 6, 2024

42 CFR 483.45 Pharmacy Service (a) 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. 42 CFR 483.45 Pharmacy Services (f) Medication Errors. The facility must ensure that its- (2) Residents are free of any significant medication errors. 22 CCR 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. § 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. On 04/12/2024, the California Department of Public Health (CDPH) received a complaint alleging the facility staff sent text to a physician regarding several resident's and specifically a resident's (Resident 1) behavior, medication regimen and request for medication. The complaint alleged the physician has asked the nurses to contact him using the physician's exchange (a reliable professional answering service), but they continue to contact him via phone text him and the administrator (ADM) did not do anything. On 4/17/2024 at 12 p.m., CDPH conducted an unannounced visit to the facility to investigate the complaint. Upon investigation, CDPH determined during the facility's pharmaceutical services transition to a new pharmacy provider, Residents 1, 2, and 3 did not receive medication as ordered by their physician's causing them to miss several doses of prescribed medication which resulted in significant medication errors. The facility failed to: 1. Ensure Resident 1, who was prescribed Clonazepam (a control medication in schedule IV [group of medicines has been associated with abuse, misuse, and diversion] used to treat anxiety, panic attacks and seizures) 1.0 milligram ([mg] a unit of measurement) for anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness) manifested by severe panic and agitation that interfered with care, did not miss 23 doses of Clonazepam 1 mg from 3/28/2024 through 4/14/2024. 2. Ensure Resident 2 did not miss four doses of Risperdal (a medication used to treat schizophrenia, and bipolar disorder) as ordered from 4/3/2024 through 4/8/2024. 3. Ensure Resident 3 did not miss five doses of Seroquel (a medication used to treat schizophrenia, bipolar disorder, and depression) from 4/9/2024 through 4/11/2024. 4. Notify the physicians for Residents 1, 2, and 3 and/or the facility's Medical Director that Resident 1 did not receive 23 doses of Clonazepam 1 mg from 3/28/2024 through 4/14/2024, that Resident 2 did not receive four doses of Risperdal from 4/3/2024 through 4/8/2024 and that Resident 3 did not receive five doses of Seroquel from 4/9/2024 through 4/1102024. 5. Ensure the facility's Policy and Procedure (P/P), titled "Pharmacy Services Overview" was followed, indicating residents should have sufficient supply of their prescribed medications and receive (routine, emergency or as needed) medications in a timely manner and nursing staff are responsible for contacting the pharmacy if a resident's medication is not available for administration. As a result of these deficient practices Residents 1, 2 and 3, did not receive prescribed medications and the facility's inability to ascertain the extent to which medications were not available to all residents residing at the facility was hampered. These deficient practices placed Residents 1, 2 and 3 at risk for symptoms of medication withdrawal (the unpleasant physical reaction that accompanies the process of ceasing to take an addictive drug) including anxiety, insomnia, restlessness, agitation, irritability, difficulty concentrating, poor memory, muscle tension, muscle aches, and depression. 1. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 69-year-old male, was admitted to the facility on 10/17/2023 with a diagnosis including anxiety disorder. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 3/7/2024, indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making were severely impaired. The MDS indicated Resident 1 had an active diagnosis of anxiety disorder. A review of Resident 1's Physician's Order dated 10/26/2023, indicated Resident 1 was to receive Clonazepam 1 mg two times a day for anxiety manifested by severe panic and agitation that interferes with needed care. A review of the Pharmacy Provider's Delivery Sheet dated 2/27/2024 and timed at 7:45 p.m., indicated 60 tablets of Clonazepam 1 mg was delivered to the facility for Resident 1 on 2/27/2024, to provide Resident 1 with medication as order from 2/27/24 through 3/27/2024. A review of Resident MAR dated 3/24/2024, indicated Resident 1 received Clonazepam 1 mg on the following days when Clonazepam was Not available in the facility: a. On 3/28/2024 at 9 a.m. and 5 p.m. b. On 3/29/2024 at 9 a.m. and 5 p.m. c. On 3/30/2024 at 9 a.m. and 5 p.m. d. On 3/31/2024 at 9 a.m. and 5 p.m. A review of the Pharmacy Provider's Delivery Sheet dated 4/7/2024 and timed at 7:38 p.m., indicated 60 tablets of Clonazepam 1 mg were delivered to the facility on 4/7/2024. A review of Resident 1's MAR dated 4/2024, indicated Resident 1 did Not receive Clonazepam 1 mg on the following days: a. On 4/3/2024 at 9 a.m. b. On 4/4/2024 at 9 a.m. c. On 4/5/2024 at 9 a.m. and 5 p.m. d. On 4/7/2024 at 9 a.m. and 5 p.m. A review of Resident 1's MAR dated 4/2024, indicated Resident 1 did not receive Clonazepam 1 mg on the following dates, when the medication was available at the facility since 4/7/2024: a. On 4/9/2024 at 9 a.m. and 5 p.m. b. On 4/11/2024 at 9 a.m. and 5 p.m. c. On 4/12/2024 at 9 a.m. and 5 p.m. d. On 4/13/2024 at 9 a.m. and 5 p.m. e. On 4/14/2024 at 9 a.m. A review of Resident 1's MAR note dated 4/3/2024 and timed at 2:14 p.m., indicated Clonazepam 1 mg was not available and the facility and the nurses were waiting on medication delivery from the pharmacy. A review of Resident 1's MAR note dated 4/5/2024 and timed at 9:13 a.m., and a subsequent MAR note on the same day, timed at 6:31 p.m., indicated Clonazepam 1 mg was not available for administration. A review of Resident 1's MAR note dated 4/9/2024 and timed at 2:12 p.m., and a subsequent MAR note on the same day, timed at 5:38 p.m., indicated Clonazepam 1 mg was pending pharmacy delivery and the estimated time of delivery was 24 to 48 hours with an estimated arrival time in the evening on 4/9/2024. A review of Resident 1's MAR note dated 4/12/2024 and timed at 1:50 p.m., indicated the pharmacy was waiting for Resident 1's physician's authorization for Clonazepam 1mg. A review of Resident 1's MAR note dated 4/13/2024 and timed at 9:41 a.m., the MAR note indicated the pharmacy was waiting on Resident 1's physician's authorization for the Clonazepam 1 mg. A subsequent MAR note on the same day, timed at 9:04 p.m., indicated the Clonazepam 1 mg was not available. A review of Resident 1's MAR note dated 4/14/2024 and timed at 9:59 a.m., the MAR note indicated the pharmacy was waiting on Resident 1's physician's authorization for the Clonazepam 1mg. A subsequent MAR note on the same day, timed at 5:36 p.m., and 8:15 p.m., indicated Clonazepam was not available and a refill was being sent by the pharmacy. During an interview on 4/18/2024 at 2:31 p.m., the Licensed Vocational Nurse (LVN 1) stated on 4/12/2024 she contacted Resident 1's physician to notify him that Resident 1 was more socially withdrawn but she did not notify him that Resident 1 had missed multiple doses of Clonazepam 1 mg. LVN 1 stated Clonazepam was not available on 4/13/2024 and 4/14/2024 because a physician's authorization was required, and the pharmacy had not sent the medication to the facility. LVN 1 stated she did not inform the Registered Nurse Supervisor 3 (RNS 3) or the Assistant Director of Nursing (ADON) regarding Resident 1's missed doses of Clonazepam 1 mg and she did not notify the Medical Director because Resident 1 was not showing any signs of restlessness or aggressive behaviors. LVN 1 stated antipsychotic medication should be slowly tapered off and not stopped abruptly because the resident could show aggressive behaviors, restlessness, or agitation. During an interview on 4/19/2024 at 4:27 a.m. and a subsequent interview on 4/22/2024 at 11:13 a.m., the facility's Clinical Consultant stated if a medication was not available the licensed nurses should investigate, call the pharmacy to check and verify if the medication was delivered to the facility. The Clinical Consultant stated the licensed nurses should notify the Director of Nursing (DON) and Administrator (ADM) when medication was unavailable so they could follow up. The Clinical Consultant stated the physician should be notified when the residents miss a dose of their medication, a Change of Condition (COC) form should be created and if the licensed nurse was unable to reach the resident's physician, the medical director should be contacted. The Clinical Consultant stated if a resident does not get the antipsychotic medication over time, there could be an escalation of an unwanted behavior. During an interview on 4/22/2024 at 11:38 a.m., Resident 1's physician stated he was not informed that Resident 1 missed multiple doses of Clonazepam. Resident 1's physician stated if a resident stops taking the antipsychotic medication, the resident may become combative, confused, depressed and aggressive. During an interview on 4/23/2024 at 8:36 a.m., and subsequent interviews on the same day at 10:14 a.m. and 1:15 p.m., the ADON stated she was unaware that Resident 1 had not received multiple doses of Clonazepam. The ADON stated according to the delivery receipts from the facility's pharmacy provider, the staff were documenting medication was administered to Resident 1 when the medication was not available in the facility. The ADON, after reviewing Resident 1's MAR, stated licensed nurses documented the number nine on Resident 1's MAR indicating to see the nurse's notes but when she reviewed the nurse's notes there was no documentation indicating why Resident 1's medication was not available for administration to Resident 1. The ADON stated if antipsychotic medication is not administered according to physician's order it can lead to residents' exhibiting aggressive behaviors or mood swings which can jeopardize the safety of the residents and facility staff. 2. A review of Resident 2's Admission Record (Face Sheet) indicated Resident 2, 77-year-old female, was admitted to the facility on 3/1/2024 with diagnoses including schizoaffective disorder (a mental health condition characterized primarily by symptoms of hallucinations or delusions) and bipolar disorder (a mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function). A review of Resident 2's MDS dated 3/6/2024, indicated Resident 2's cognitive skills for daily decision making was intact. A review of Resident 2's Physician's Order dated 3/1/2024, indicated Resident 2 was to receive Risperdal 2 mg at bedtime for schizoaffective disorder manifested by aggression that may interfere with needed care. A review of the facility's Pharmacy Providers Delivery sheet, indicated on 3/2/2024, 30 tablets of Risperdal 2 mg were delivered to the facility, to provide Resident 2 with medication as order until 4/1/2024. A review of Resident 2's MAR dated 4/2024, indicated Resident 2 received Risperdal on 4/2/2024 through 4/4/2024 and 4/6/2024 through 4/8/2024 when Risperdal was no longer available in the facility. A review of Resident 2's MAR dated 4/2024, indicated Resident 2 did not receive Risperdal on 4/5/2024 and 4/9/2024. A review of the facility's Pharmacy Providers Delivery Sheet, indicated on 4/10/2024, 14 tablets of Risperdal 2 mg were delivered to the facility, to provide Resident 2 with medication as order until 4/24/2024. During an interview on 4/23/2024 at 8:36 a.m., and subsequent interviews on the same day at 10:14 a.m., and 1:15 p.m., the ADON stated for Resident 2, according to the delivery receipts, the facility would have no supply of the medication after 4/2/2024 but facility staff were still documenting medication was administered 4/3/2024 and 4/4/2024. 3. A review of Resident 3's Admission Record (Face Sheet) indicated Resident 3, 80-year-old male, was admitted to the facility on 12/19/2023 with a diagnosis of schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A review of Resident 3's MDS dated 3/27/2024, indicated Resident 3's cognition was severely impaired. A review of Resident 3's Physician's Orders dated 12/28/2024, indicated Resident 3 was to receive the following Medications: a. Seroquel 100 mg once a day for aggression which causes interference with needed care. b. Seroquel 150 mg at bedtime for aggression which causes interference with needed care. A review of the facility's Pharmacy Providers Delivery sheet indicated on 3/26/2024, 14 tablets of Seroquel 100 mg was delivered to the facility, to provide Resident 3 with medication as order through 4/9/2024. A review of Resident 3's MAR dated 4/2024, indicated Resident 3 did not receive Seroquel on 4/2/2024 at 9 a.m., 4/9/2024 at 9 a.m., when Seroquel should have been available for administration to Resident 3. The MAR indicated Resident 3 did not receive Seroquel 4/10/2024 at 9 a.m. A review of the facility's Pharmacy Providers Delivery sheet, indicated on 4/11/2024, 54 tablets of Seroquel 100 mg was delivered to the facility. A review of facility's Pharmacy Providers Delivery sheet, indicated on 4/12/2024, 27 tablets of Seroquel 50 mg was delivered to the facility. A review of Resident 3's MAR note dated 4/11/2024, indicated Seroquel was not available and it was pending delivery from the pharmacy. A review of Resident 3's COC note dated 4/11/2024, indicated the facility was waiting for pharmacy to deliver the Seroquel and Resident 3's physician was notified regarding missed dose since 4/9/2024. During an interview on 4/19/2024 at 12:26 p.m., LVN 3 stated she did not administer Seroquel to Resident 3 on 4/2/2024 and 4/9/2024 (it was available, see above) because it was pending delivery from the pharmacy and not available in the facility. LVN 3 stated on 4/11/2024, Resident 3 did not receive a dose of Seroquel because it was not available and she notified pharmacy, the physician, and initiated a COC. LVN 3 stated a COC should be started when a resident does not receive their medication for three days. During an interview on 4/19/2024 at 4:27 a.m. and a subsequent interview on 4/22/2024 at 11:13 a.m., the Clinical Consultant stated if a medication was not available the licensed nurse should investigate, call the pharmacy to check and verify if it was delivered to the facility. The Clinical Consultant stated the licensed nurse should notify the DON and ADM so they are aware and can follow up. During an interview on 4/22/2024 at 1:43 p.m., the facility's new Pharmacy Provider stated the transition to the new pharmacy occurred o