Health inspection·September 27, 2023

F755 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §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.

F760 The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. An unannounced visit was conducted by California Department of Public Health on 8/2/23 at 9:51 AM to investigate a facility reported incident regarding an allegation of patient- to- patient altercation and medications not given according to the physician’s order. The facility failed to provide pharmaceutical services for Patient 1 and failed to ensure the patient was free from significant medication error (mean the identified preparation or administration of medications was not in accordance with the physician's order) by: 1. Failing to administer Patient 1’s Fluoxetine (antidepressant; medication used to treat depressive disorder) and four supplements (product intended to supplement one's diet by taking a pill, capsule, tablet, powder, or liquid) on his dialysis (process of removing excess water, and toxins from blood in people whose kidneys [organ that helps removes waste, extra water and makes urine] no longer performs these functions) days. There were total of 14 days the medications were not given to the patient from 7/1/2023 to 8/3/2023. 2. Failing to notify Patient 1’s primary physician of the patient’s missed medications on total of 14 days from 7/1/2023 to 8/3/2023. These deficient practices placed Patient 1 at risk of not getting the full effect of the medication and resulted in the patient having increased behavior episodes of feeling sadness. Patient 1 had 32 episodes of verbalizing of feeling of sadness on 6/2023 while there was 34 episodes on 7/2023. A review of Patient 1’s Admission Record, indicated the patient is a 53- year- old- male who was originally admitted to the facility on 11/6/2021 and was readmitted on 4/17/2023 with the diagnosis of epilepsy (a seizure disorder in which nerve cell activity in the brain is disturbed) and depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Patient 1’s History and Physical (H&P), dated 4/19/2023, indicated the patient is able to make decisions. A review of the Patient 1’s Minimum Data Set (MDS; a standardized assessment and care screening tool), dated 6/1/2023, indicated Patient 1 is moderately cognitively impaired for daily decision making. The MDS also indicated during an interview with Patient 1, the patient has been feeling down, depressed, and hopeless for 2-6 days over the last two weeks. The MDS indicated the patient required extensive one person assist (patient involved in activity, staff provide guided maneuvering) for bed mobility, dressing, toilet use and personal hygiene. A review of Patient 1’s physician order, dated 6/21/2023, indicated the following orders: a. Administer Fluoxetine Oral Tablet 20 milligrams (mg; unit of measure) once a day for major depressive disorder. b. Administer Arginald oral packet (nutritional supplement that helps the body to build protein). Give 1 packet by mouth two times a day. c. Calcium Citrate Tablet 250 mg (supplement for bone health). Give 1 Tablet by mouth one time a day. d. Administer Rena-Vite Oral Tablet (B-Complex [increase energy levels, reduce stress, boost mood, and reduce symptoms of anxiety or depression] with vitamin C and folic acid [important in red blood cell formation and for healthy cell growth and function]). Give 1 tablet by mouth one time a day. e. Administer vitamin C oral tablet 500 mg. Give 1 tablet by mouth one time a day. f. Resident 4 to have dialysis on Tuesdays, Thursdays, and Saturdays at 8 AM. A review of Patient 1’s care plan, revised on 6/19/2023, indicated to administer meds Fluoxetine 20 mg daily as ordered. A review of Patient 1’s “Psychoactive (of or relating to a substance having a profound or significant effect on mental processes) and Sedative (promoting calm or inducing sleep)/Hypnotic (sleep inducing) Assessment (assess the effectiveness of psychotropics (drug taken to exert an effect on the chemical makeup of the brain and nervous system [includes the brain, spinal cord, and a complex of nerves that sends message back and forth between the brain and the body] such as antidepressants)”, dated from 6/2023 to 7/2023, indicated, Patient 1 had 32 behavior episodes of feeling sadness on 6/2023 and 34 behavior episodes of feeling sadness on 7/2023. During an interview on 8/3/2023 at 10:28 AM, Licensed Vocational Nurse (LVN) 1 stated there was no order for Patient 1 to take his medications after dialysis. LVN 1 also stated Patient 1 did not get his medication during his dialysis days from 7/1/2023 to 8/3/2023 (total of 14 days) and there is no order for the patient to take it after dialysis. During an interview on 8/3/2023 at 11:05 AM, the Director of Nursing (DON) the licensed nurse should have contacted Patient 1's primary physician to verify if the above medications should have been given to the patient after the patient returned from dialysis treatment every Tuesday, Thursday and Saturdays. During a concurrent interview on 8/3/2023 at 11:30 AM with LVN 1 and record review of Patient 1’s Medication Administration Record (MAR; a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for the month of 7/2023 and 8/2023, indicated the Fluoxetine, Calicum Citrate tablet, Rena-Vite tablet, vitamin C and Arginald oral packet were signed as code number two (2) or five (5) on the following days: 1. On 7/1/2020, 7/6/2023, 7/8/2023, 7/13/2023, 7/15/2023, 7/22/2023, 7/27/2023, and 7/29/2023, the five (5) medications were coded 5. LVN 1 stated, code 5 meant the patient was on dialysis and medications were not given to the resident. 2. On 7/4/2023, 7/11/2023, 7/18/2023, 7/20/2023, 7/25/2023 and 8/1/2023 the 5 medications were coded 2. LVN 1 stated, code 2 meant the patient was not available, and the medication was not given to the resident. LVN 1 stated, there were total of 14 days from 7/2023 to 8/3/2023 that Patient 1 did not get his medications. During the same interview with LVN 1 and record review of Patient 1’s MAR for 7/2023 and 8/2023, LVN 1 stated the numbers documented in the monitoring for depression (mood disorder that causes of persistent feeling of sadness and loss of interest which can affect variety of emotional and physical illness) as manifested by expressing of feeling of sadness in the MAR meant the number of times the patient expressed that patient was sad. The MAR indicated on 7/1/2023 to 8/3/2023 Patient 1 had 37 (34 on 7/2023 and three [3] on 8/2023) documented episodes of depression. During an interview on 8/3/2023 at 11:36 AM, Nurse Practitioner (NP) stated she was not made aware by the facility staff that Patient 1 was not receiving his Fluoxetine on his dialysis days. During an interview on 8/3/2023 at 12 PM, the DON stated if the patient has morning medication and goes to dialysis, there should be an order to give the patient his medications after dialysis. The DON also stated missed medications such as antidepressant (Fluoxetine) and vitamins or supplements can cause a change in behavior if not taken as ordered and for Patient 1 to not receive the supplements he needed. A review of the facility’s policy and procedure titled “Care Plans, Comprehensive Person-Centered”, revised 3/2022, indicated interventions address the underlying source(s) of the problem area(s). A review of the facility’s policy and procedure titled “Administering Medications”, revised 4/2019, indicated medications are administered in accordance with prescriber orders, including any required time frame. Policy also indicated medication administration times are deterred by patient need and benefit, not staff convenience which include enhancing optimal therapeutic effect of the medication. The facility failed to provide pharmaceutical services for Patient 1 and failed to ensure the patient was free from significant medication error (mean the identified preparation or administration of medications was not in accordance with the physician's order) by: 1. Facility failed to administer Patient 1’s Fluoxetine (antidepressant; medication used to treat depressive disorder) and four supplements (product intended to supplement one's diet by taking a pill, capsule, tablet, powder, or liquid) on his dialysis (process of removing excess water, and toxins from blood in people whose kidneys [organ that helps removes waste, extra water and makes urine] no longer performs these functions) days. There were total of 14 days the medications were not given to the patient from 7/1/2023 to 8/3/2023. 2. Facility failed to call and notify Patient 1’s primary physician of the resident’s missed medications on total of 14 days from 7/1/2023 to 8/3/2023. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.