Health inspection·April 18, 2023

§ 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. (7) Patients shall be identified prior to administration of a drug or treatment. (b)No medication shall be used for any patient other than the patient for whom it was prescribed. § 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. F760 §483.45(f)(2) Residents are free of any significant medication errors. An unannounced visit was conducted by California Department of Public Health on 3/1/23 at 11 AM to investigate a facility reported incident regarding an allegation of patient- to- patient sexual abuse. The facility failed to ensure Patient 1 was free from significant medication error (one or more observed or identified preparation or administration of medications ordered by a physician causing the patient discomfort or jeopardizes his or her health and safety). On 2/26/23, the licensed nurse (RN1) did not properly check and identify the patient prior to administering medications. RN1 erroneously administered eight (8) medications to Patient 1 belonging to Patient 2. This deficient practice resulted in Patient 1 to experience adverse effects that included nausea, vomiting, dizziness, and malaise (feeling of being unwell and feeling tired). Patient 1 was transferred to the General Acute Care Hospital (GACH) due to the adverse reactions to the medications. A review of Patient 1’s admission record indicated the patient is a 83- year- old- female who was readmitted to the facility on 4/4/22, with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke, damage to the brain due to interruption of blood supply) affecting the left side and type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of Patient 1’s Minimum Data Set (MDS – a comprehensive assessment and care-screening tool) dated 1/5/23, indicated patient was assessed to have severe impairment with cognitive skills (ability to understand and make decisions). The MDS also indicated Patient 1 required limited assistance from one facility staff when eating and extensive assistance from one facility staff during dressing and personal hygiene. A review of Patient 1’s “eINTERACT Change in Condition Evaluation” form (COC form) dated 2/26/23 entered at 2:01 PM, indicated, Patient 1 had change of condition of vomiting, body weakness and severe frontal lobe (forehead, front part of the brain. It controls high level cognitive skills and primary motor function [activity or movement of the body]) headache. A review of Patient 1’s progress notes (general) dated 2/26/23 entered at 2:48 PM, indicated, Patient 1 was taken to the GACH via 911 at 2:27 PM due to nausea, vomiting and chills. A review of Patients 1’s care plan (documentation of information that easily described the services, care and support being given to the patient), dated 2/26/23 indicated Patient 1 had episodes of vomiting, body malaise, and severe headache secondary to medication error. A review of Patient 1’s untitled GACH record dated 2/26/23, indicated the patient was seen by the GACH doctor on 2/26/23 at 2:31 PM. The GACH record indicated, the patient was sent to their Emergency Department (ED) from the facility due to dizziness with onset of 30 minutes prior to arrival. The GACH record also indicated, Patient 1 received her regular dose of medication for hypertension (elevated blood pressure) earlier that day, but then was accidentally given another patient’s medication for hypertension. A review of Patient 1’s progress notes (IDT, interdisciplinary team [team consist of doctors, licensed nurses, social services and/ or dietary supervisor) dated 2/28/23 entered at 8:36 PM, indicated, Patient 1 received medications that belonged to another patient. A review of Patient 2’s admission record indicated the patient was readmitted at the facility on 11/18/22, with diagnoses that included type 2 DM, hydronephrosis (excess water in the kidney due to back up of urine) with renal (kidney) and ureteral calculous obstruction (blockage in one or both tubes that carry urine from kidneys to the bladder). A review or Patient 2’s medication review report dated 3/2/203, indicated the following medication order: 1. metformin hydrochloride (Metformin HCL, medication for DM) tablet give 500 (mg, unit of measurement) by mouth two (2) times a day with meals 2. sacubitril – valsartan (Entresto, medication for hypertension for patients with kidney disease) 24- 26 mg give 1 tablet by mouth two times a day for hypertension 3. metoprolol tartrate (medication for high blood pressure) tablet give 2.5 mg by mouth two times a day 4. aspirin (reduce risk of serious problems like heart attacks and strokes) oral tablet give 325 milligrams (mg, unit of measurement) one time a day 5. ascorbic acid (vital to body’s healing process) oral tablet give 500 mg two times a day 6. calcium with vitamin D (supplement for bone, nervous system, musculoskeletal, and immune system) oral tablet 500 mg, give 1 tablet by mouth one time a day 7. docusate sodium (Colace, treats occasional constipation) tablet, give 100 mg by mouth two times a day 8. multi-vitamin (dietary supplement containing all or most of the vitamins that may not be readily available in the diet) oral tablet give one tablet by mouth During an interview with Patient 1 on 3/1/23 at 12:54 PM, the patient stated on 2/26/23 between 11:00 AM to 11:30 AM (unable to recall specific time), Registered Nurse 1 (RN 1) was giving medications that she did not know what medications to the patient. The patient stated she told RN 1 more than once that she was already given medications in the morning. Patient 1 stated, RN 1 did not respond to the patient’s comment and continued to administer the crushed medications in her mouth. Patient 1 stated, on the same date (2/26/23) after a few minutes after RN 1 gave her the unknown medications, Patient 1 began to feel dizzy, shaky, vomiting, headache, eyes felt heavy, and cold. Patient 1 also stated, Licensed Vocational Nurse 1 (LVN 1) told her on the same day she would be transferred to the GACH. During an interview with certified nurse assistant (CNA 1) on 3/1/23 at 1:20 PM, CNA 1 stated on 2/26/23 sometime prior to 12:30 PM Patient 1 informed CNA 1 that the patient was feeling dizzy, had a headache, and that the patient’s “head felt heavy”. CNA 1 stated, Patient 1 would not stop vomiting. During an interview with the Director of Nursing (DON) on 3/1/23 at 2:05 PM, the DON stated RN 1 did not identify Patient 1 by checking the patient’s photo from the electronic medication administration record (eMar) and did not check the patient’s wrist band to verify name, date of birth, and room number prior to administering all eight (8) medications that belonged to Patient 2. The DON stated the medication error was discovered when LVN 1 witnessed RN 1 giving Patient 1 medications with a spoon on 2/26/23, between 11AM to 11:10AM. During the same interview with the DON on 3/1/23 at 2:10 PM, the DON also stated the medications given to Patient 1 in error on 2/26/23 that included sacubitril – valsartan which can cause some stomach upset and metformin could have led the patient to experience vomiting, body weakness and headache due to hypoglycemia (low blood sugar level) requiring the patient to be transferred to the GACH on the same day. During a concurrent review of Patient 2’s eMAR for the month for February 2023 and interview with the DON, the DON stated RN 1 admitted to her that RN 1 administered the 8 medications of Patient 2 to Patient 1 on 2/26/23 in error. The DON stated, according to Patient 2’s eMAR, the 8 medications were: 1. Metformin HCL tablet 500 mg by mouth 2. sacubitril – valsartan 24- 26 mg by mouth 3. metoprolol tartrate tablet give 2.5 mg by mouth 4. aspirin oral tablet give 325 milligrams mg by mouth 5. ascorbic acid oral tablet give 500 mg by mouth 6. calcium with vitamin D oral tablet 500 mg tablet by mouth 7. docusate sodium 100 mg tablet by mouth 8. multi-vitamin oral tablet give one tablet by mouth During an interview with Registered Nurse Supervisor (RNS) on 3/1/23 at 2:50 PM, RNS stated on 2/26/23 (unable to recall time) RN 1 approached him and asked who Patient 2 was. RNS informed RN 1, the patient was “the lady on my left.” RNS stated shortly after, LVN 1 approached him questioning as to why RN1 gave medications to Patient 1. RNS stated he attempted to talk to RN 1 to verify medications given to the patient, but RN 1 walked away from him. RNS stated shortly after RN 1 allegedly administered Patient 1 medications, the patient started having adverse reactions (undesired effect of the drug). During a telephone interview with RN 1 on 3/1/23 at 3:12 PM, RN 1 stated, on 2/26/23 during the morning shift (unable to recall specific time) RN 1 stated, she asked RNS Who Patient 2 was and RN 2 replied, it was “the patient on my left.” RN 1 stated she thought RNS gestured pointing to Patient 1. RN 1 then stated she prepared 8 medications (metformin, sacubitril – valsartan, metoprolol, aspirin, ascorbic acid, calcium with vitamin D, Colace, and multivitamins) by crushing them and spoon fed them to Patient 1 around 11am-11:10am. RN1 stated RNS informed her she had administered the wrong medications to the wrong patient shortly after she administered Patient 2’s medications. RN 1 stated, she did not identify Patient 1 properly prior administering the patient medications by checking the patient’s wrist band, by photo identification (ID), patient self-identification, or using other staff to verify and identify the actual patient. A review of the facility policy and procedure (P&P) titled, “Resident Identification System”, revised December 2007, indicated a resident identification system is used to help facility personnel provide medical and nursing care which include: 1. The facility has adopted a photo and/ or wristband identification system to help assure that medication and treatments are administered to the right resident. 2. The photo identification or wristband identification is used by nursing service personnel when administering medications and treatments. A review of the facility’s P&P titled, “California Long Term Care (LTC) Facility’s Pharmacy Services and Procedures Manual,” revised on 4/1/22, indicated prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. The P&P indicated during medication administration, facility staff should take all measures required by facility policy and applicable law including identify the resident per facility policy. The facility failed to ensure Patient 1 was free from significant medication error. On 2/26/23, the licensed nurse (RN1) did not properly check and identify the patient prior to administering medications. RN1 erroneously administered eight (8) medications to Patient 1 belonging to Patient 2. This deficient practice resulted in Patient 1 to experience adverse effects that included nausea, vomiting, dizziness, and malaise (feeling of being unwell and feeling tired). Patient 1 was transferred to the General Acute Care Hospital (GACH) due to the adverse reactions to the medications. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.