Other·April 25, 2024

Code of Federal Regulations, Title 42, Section 483.45(f)(2) The facility must ensure that its— §483.45(f)(2) Residents are free of any significant medication errors. California Code of Regulations, Title 22, Section 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. California Code of Regulations, Title 22, Section 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. On 3/28/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding quality of care, nursing services, and administration. As a result of the investigation, CDPH determined the facility failed to ensure Resident 1 was free from significant medication error (medication error which causes the resident discomfort or jeopardizes the resident health and safety) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 administered fluticasone furoate suspension (Flonase- nasal spray medication used to treat nasal congestion, sneezing, and runny nose caused by seasonal allergies) instead of Narcan nasal liquid (nasal spray medication used to rapidly reverse the effects of opioid [class of drugs used to treat moderate to severe pain] overdose) to Resident 1 on 3/14/2024 at 7:00 pm. 2. Ensure LVN 1 checked Resident 1’s Narcan nasal liquid medication label three times and verified that it was the right medication, right dosage, and right time before administering the medication to Resident 1 as indicated in the facility’s policy and procedure (P&P) titled, “Administering Medications.” As a result of these violations, on 3/17/2024 at 7:00 pm, immediately after Resident 1 received the incorrect medication, Resident 1 experienced chest pain, burning sensation of Resident 1’s body, and Resident 1 felt like Resident 1 was “dying.” Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 3/14/2024 at 7:30 pm for further evaluation and was treated for acute opioid withdrawal induced by accidental Narcan administration. A review of Resident 1’s Admission Record, indicated the facility admitted Resident 1, a 78-year-old male, to the facility on 8/16/2022, with diagnoses of asthma, allergic rhinitis, acquired absence of right leg above the knee and phantom limb syndrome with pain. A review of Resident 1’s Physician Order (PO), dated 8/16/2022, indicated Resident 1 had an order for fluticasone furoate suspension, 27.5 micrograms (mcg), spray one (1) spray in both nostrils, two times a day related to adverse effect of anti-asthmatics. A review of Resident 1’s Minimum Data Set (MDS), dated 2/13/2024, indicated Resident 1 had intact cognition. The MDS indicated, Resident 1 required supervision or touching assistance with oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting/taking off footwear, and personal hygiene. A review of Resident 1’s PO, dated 2/14/2024, indicated Resident 1 had an order for Percocet (a combination medication containing oxycodone [an opioid pain medication] and acetaminophen [medication used to treat mild to moderate pain and fever] oral tablet 5-325 milligrams (mg), give one (1) tablet by mouth every six (6) hours as needed for pain. A review of Resident 1’s PO, dated 2/14/2024, indicated Resident 1 had an order for Narcan nasal liquid (Naloxone Hydrochloride [HCl]), one (1) spray in nostril as needed for opioid overdose. A review of Resident 1’s Progress Notes (PN), dated 3/14/2024 at 7:38 pm, indicated at approximately 7:00 pm, LVN 1 administered nasal spray (unidentified) to Resident 1. The PN indicated, LVN 1 retrieved a box containing nasal spray (naloxone HCl nasal spray) labeled with Resident’s 1 name. The PN indicated, immediately after administration of the nasal spray, Resident 1 began to shout and complain of chest pain, burning sensation of Resident 1’s body, and felt like Resident 1 was “dying.” The PN indicated, Resident 1 complained that Resident 1’s body was on fire and Resident 1’s nose was burning. The PN indicated, Resident 1’s blood pressure was 142/94 millimeters of mercury (mmHg) (Normal BP was 120/80). The PN indicated, the facility called paramedics. A review of Resident 1’s PO, dated 3/14/2024, indicated an order to transfer Resident 1 to GACH 1 via 911 on 3/14/2024 (no time and indication specified). A review of Resident 1’s GACH 1 Emergency Department Exam Narrative (ED Exam), dated 3/14/2024 at 7:47 pm, indicated Resident 1 was brought in for accidental medication administration of Narcan, eight (8) mg. The ED Exam indicated, Resident 1 was normally on Percocet and occasionally on Morphine (opioid pain medication used to treat moderate to severe pain) for chronic pain. The ED Exam indicated, Resident 1 was very anxious and restless and was in acute withdrawal due to Narcan. The ED Exam indicated, Resident 1’s blood pressure was 170/80 mmHg. The ED Exam indicated, Resident 1 was treated with buprenorphine (medication used to treat opioid use disorder), clonidine HCI (medication used to lower blood pressure and heart rate), and intravenous (into a vein) fluids. During an interview on 3/28/2024 at 9:05 am, Resident 1 stated LVN 1 was Resident 1’s medication nurse in the afternoon (on 3/14/2024). Resident 1 stated LVN 1 handed him a nasal spray medication that did not look familiar to him. Resident 1 stated he explained to LVN 1 that it was not his “normal nasal spray” medication, but LVN 1 insisted it was the correct nasal spray medication for Resident 1. Resident 1 stated he explained to LVN 1 that he normally took Flonase and not “Naloxona.” Resident 1 stated LVN 1 told him to take the medication because it was prescribed to him and was due to be taken. Resident 1 stated LVN 1 made him take the Narcan. Resident 1 stated immediately after LVN 1 sprayed the Narcan into his nostril, his body felt like it was burning. Resident 1 stated he wanted to remove all his clothes because Resident 1’s body felt like “it was on fire.” Resident 1 stated he felt “different” in his head like his head was “going to explode.” Resident 1 stated he urinated and vomited on himself. Resident 1 stated he started to scream and ask for help because he felt like he was going to die. Resident 1 stated after he returned to the facility from GACH 1, he still experienced some chest pain and body tingling. Resident 1 stated he had never been more scared in his entire life than in that moment when he received the wrong medication. During an interview on 3/28/2024 at 12:02 pm, LVN 1 stated when giving medications, LVN 1 did not check the medication label on the nasal spray before administering the medication to Resident 1 (on 3/14/2024 at 7 pm). LVN 1 stated she normally checked the resident’s name, medication order, and matched the information against the medication label to ensure she had the right dose of medication, right time, right patient, right medication, and right route of administering the medication. LVN 1 stated on 3/14/2024 at approximately 7 pm, LVN 1 thought she was giving Resident 1 Flonase nasal spray. LVN 1 stated she had trouble finding the Flonase in the medication cart. LVN 1 stated she found a box of nasal spray with Resident 1’s name on it but did not look at the name/label of the medication or the bottle of the medication. LVN 1 stated after giving the nasal spray to Resident 1, she left Resident 1’s room to get Resident 1’s prescribed narcotic (medication used to treat moderate to severe pain). LVN 1 stated Resident 1 then wheeled himself into the hallway screaming, “My body is on fire. I’m going to die. My chest, my chest!” LVN 1 stated Resident 1 vomited. LVN 1 stated at that time, she did not know what was happening to Resident 1. LVN 1 stated the desk nurse called 911 (a phone number used to contact the emergency services). LVN 1 stated when the paramedics arrived, the paramedics asked for the medications administered to Resident 1. LVN 1 stated she showed the paramedics the box of nasal spray she thought was Flonase and administered to Resident 1. LVN 1 stated the paramedics told LVN 1 that she gave Resident 1 the Narcan. LVN 1 stated she accidentally gave Resident 1 the Narcan. LVN 1 stated it was important to check medication label and bottle to ensure the medication being given was the correct medication. LVN 1 stated not checking the medication bottle/label before giving the medication to Resident 1 caused Resident 1 harm and could have led to Resident 1’s death. LVN 1 stated if she checked the bottle/label of nasal spray before administering it to Resident 1, the medication error could have been avoided. During a telephone interview on 3/28/2024 at 1:36 pm, the Pharmacist Consultant (PC) 1 stated Narcan was administered only in the event of a suspected or confirmed opioid overdose situation. PC 1 stated Narcan would be administered if a resident was experiencing respiratory depression, lethargy, or unresponsiveness. PC 1 stated Narcan diminished the effects of opioids. PC 1 stated Resident 1 had an adverse response to Narcan because it caused vomiting and hypertension. PC 1 stated LVN 1 made a medication error because Resident 1 was not experiencing opioid overdose when LVN 1 administered the Narcan to Resident 1. PC 1 stated LVN 1 could have avoided the medication error if LVN 1 followed the five rights of medication administration (right medication, right dose, right time, right route, right patient). During an interview on 3/28/2024 at 4:44 pm, the Director of Nursing (DON) stated the five rights of medication administration needed to be followed during medication pass to ensure mistakes or medication errors were not made. The DON stated if the licensed nurses did not follow the five medication rights, medication errors could be made. The DON stated giving a resident Narcan when not indicated could cause a resident to experience increased heart rate, hypertension, anxiety, agitation, and acute opioid withdrawal. The DON stated LVN 1 did not follow the five rights of medication administration before administering the Narcan to Resident 1. The DON stated the medication error and Resident 1’s adverse reaction could have been avoided had LVN 1 followed the five medication rights. During a review of the facility’s P&P titled, “Administering Medications,” revised in 4/2019, the P&P indicated, medications were administered in a safe and timely manner, and as prescribed. The P&P indicated, medications were administered in accordance with prescriber orders, including any required timeframe. The P&P indicated, individuals administering medications checked the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The facility failed to ensure Resident 1 was free from significant medication error by failing to: 1. Ensure LVN 1 administered fluticasone furoate suspension instead of Narcan nasal liquid to Resident 1 on 3/14/2024 at 7:00 pm. 2. Ensure LVN 1 checked Resident 1’s Narcan nasal liquid medication label three times and verified that it was the right medication, right dosage, and right time before administering the medication to Resident 1 as indicated in the facility’s P&P titled, “Administering Medications.” As a result of these violations, on 3/17/2024 at 7:00 pm, immediately after Resident 1 received the incorrect medication, Resident 1 experienced chest pain, burning sensation of Resident 1’s body, and Resident 1 felt like Resident 1 was “dying.” Resident 1 was transferred to GACH 1 on 3/14/2024 at 7:30 pm for further evaluation and was treated for acute opioid withdrawal induced by accidental Narcan administration. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.