Health inspection·September 15, 2022

F760 The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. T22 72313 (a) (2) § 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. T22 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 8/3/2022 at 10:45 am, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care. The facility failed to follow its policy and procedure on “Medication Orders,” to prevent significant medication errors (medication errors that causes the patient discomfort or jeopardizes the patient health and safety) for Patient 1 by failing to: 1. Ensure Registered Nurse 1 (RN 1) checked Patient1’s name on the Physician Admission Order (medication list) when she transcribed (to make a full written or typewritten copy of dictated material), the medication list into the Physician Order Sheet in the facility’s Point Click Care system (PCC, healthcare software used for electronic health record). RN 1 entered the medication list that belonged to Patient 2 (another hospice [a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness] patient who was not a patient at the facility) into the PCC system for Patient 1. 2. Ensure RN 1 verify Patient 1’s Physician Admission Orders with an attending physician during admission when RN 1 admitted Patient 1 to the facility as indicated in the facility’s policy. As a result, for 4 days (from admission on 5/27/2022 to discharge on 5/31/2022), Patient 1 received 13 medications that were not prescribed to him {1. Benazepril (medication to treat high blood pressure); 2. Clonidine (medication to treat blood pressure); 3 Glipizide (medication to treat high blood sugar) 4. Hydrochlorothiazide (mediation to treat high blood pressure); 5. Isosorbide Mononitrate (medication to treat chest pain for coronary artery disease); 6. Januvia (medication to treat high blood sugar). 7. Lasix (medication to reduce extra fluid in the body to treat high blood pressure); 8 Levothyroxine (medication to treat underactive thyroid gland); 9. Memantine (medication to treat memory loss); 10. Plavix (blood thinner); 11. Pravastatin Sodium (medication to lower the amount of cholesterol in the blood and to prevent stroke and heart attack); 12. FeroSul (an iron supplement to treat or prevent low blood level of iron), 13. Pepcid (medication to prevent and treat heart burns and other symptoms caused by too much acid in the stomach)} that were not prescribed for the patient. Patient1 also did not receive 6 medications that were prescribed for him {1. Centrum Silver Multivitamin (supplement); 2. Diltiazem Hydrochloride (medication to treat high blood pressure; 3. Magnesium (supplement); 4. Metamucil (medication to help with bowel movement), 5. Propranolol (medication to treat high blood pressure); 6. Senna (medication to relieve occasional constipation)}. These deficient practices placed Patient 1 at risk to experience adverse side effects (unintended pharmacologic effects that occur when a medication is administered incorrectly) from these significant medication errors. A review Patient 1’s Admission Record indicated the facility admitted an eighty-nine-year-old-male patient on 5/27/2022 from home with diagnoses of malignant neoplasm of connective and soft tissue (cancer of soft tissues that surrounds or supports internal organs and bones), malignant neoplasm of the bronchus or lung (lung cancer) and hypertension (high blood pressure). A review of Patient 1’s Clinical Admission Evaluation, dated 5/27/2022 and timed at 2 pm, indicated Patient 1 was admitted to the facility for respite care (temporary care given to a person who is unable to care for himself or herself so that the usual caregivers can have a break). The evaluation indicated Patient 1 had clear speech, usually understand others, and usually made self-understood. Patient 1 had unsteady gait and was able to move all extremities with no impairment. A review of Patient 1’s Baseline Care Plan and Summary, dated 5/27/2022 and timed at 2 pm, indicated Patient 1 required set up help only for eating, one-person physical assist for personal hygiene, toilet use, dressing, transfer and walk in room. Patient 1 was alert upon admission. Patient 1 had impaired cognitive status manifested by confusion and forgetfulness. A review of the facility’s Order Summary Report dated 5/27/2022, indicated Patient 1 was prescribed: 1. Acetaminophen Suppository (medication to treat mild to moderate pain), 650mg, inserted rectally (insert into the rectum), every 4 hours as needed for pain or temperature greater than 100 Fahrenheit (F). 2. Ambien tablet (medication to treat anxiety and induce sleep), 5mg, give 1 capsule by mouth at bedtime for inability to sleep. 3. Benazepril Hydrochlorothiazide (HCI, class of medication know as diuretics/water pills), 20mg, give 1 tablet by mouth in the morning for hypertension (HTN, increased blood pressure). 4. Bisacodyl Suppository (medication to treat constipation), insert 10mg, rectally every 24 hours as needed for constipation. 5. Clonidine HCI tablet (medication to treat high blood pressure), 0.1mg, give1 tablet by mouth one time a day for hypertension. 6. Fentanyl patch 72-hour (medication to treat severe pain), 50mcg/hr (microgram per hour) apply 1 patch transdermal (through skin) in the afternoon every 3 days for pain management. 7. FeroSul tablet 325mg, give 1 tablet by mouth two times a day for anemia (lack enough healthy red blood cells to carry oxygen to body). 8. Flomax (medication to treat urinary problem caused by an enlarged prostate), 0.4mg, give 1 capsule by mouth at bedtime for enlarged prostate gland. 9. Glipizide tablet, 5mg, give 1 tablet by mouth one time a day for type 2 diabetes mellitus (DM2, a chronic condition that affects the way your body metabolizes sugar). 10. Hydrochlorothiazide tablet, 12.5mg, give 1 tablet by mouth in the morning for high blood pressure/fluid retention. 11. Hyoscyamine Sulfate (medication to treat stomach problem such as cramps) tablet 0.125mg give 1 tablet by mouth every 4 hours as needed for increase secretions. 12. Isosorbides Mononitrate tablet give 30mg by mouth in the morning for HTN, Januvia tablet 25mg give 1 tablet by mouth in the morning for DM2. 13. Lasix tablet 20mg give 1 tablet by mouth in the morning for fluid retention. 14. Levothyroxine Sodium tablet give 100mg by mouth one time a day for hypothyroidism (a condition where the thyroid doesn’t create and release enough thyroid hormone into your bloodstream). 15. Lorazepam tablet (medication to treat anxiety), 0.5mg give 1 tablet by mouth every 2 hours as needed for anxiety, memantine HCI tablet 5mg give 1 tablet by mouth in the morning for Alzheimer’s. 16. Percocet tablet (mediation to treat moderate to severe pain), 7.5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain. 17. Pepcid Tablet, 20mg, give 1 tablet by mouth two times a day for gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach causing burning sensation). 18. Plavix tablet, 75mg, give 1 tablet by mouth in the morning for deep vein thrombosis (DVT, blood clot in a vein) prophylaxis. 19. Pravastatin Sodium tablet, 40mg, give 1 tablet by mouth at bedtime for hyperlipidemia (HLD, too much fat in the blood). 20. Zofran tablet (medication to prevent nausea and vomiting), 4mg, give 1 tablet by mouth every 8 hours as needed for nausea/vomiting. A review of Hospice Nurse 1’s (HN 1’s) medication list (List 1) faxed to the facility on 5/27/2022 with fax stamp timed at 3:47pm, indicated Patient 1 was prescribed the following medications: 1. Centrum Silver Multivitamin, 1 tab (tablet), oral, once daily for supplement; 2. Diltiazem hydrochloride, 360mg, 1 tab, oral, once daily for Afib (Atrial Fibrillation, a type of arrhythmia or abnormal heartbeat); 3. Magnesium, 500mg, 1 tab, oral, once daily for supplement; 4. Metamucil (fiber supplement), 1 table spoon (tsp), oral, once daily for laxative; 5. Percocet 7.5mg/325mg, 1 tab, oral, every 4 hours as needed for pain; 6. Propranolol, 40mg, 1 tab, oral, twice a day for hypertension; 7. Senna, 8.6mg, 2 tablets, orally daily for prevent constipation; 8. Flomax, 0.4mg, 1 capsule, oral, daily for BPH; 9. Imodium Advance (medication to treat diarrhea), 2mg-125mg, 2mg 1-2 tablets, oral, for diarrhea; 10. Fentanyl 50mcg/hr, transdermal (through skin) patch, 50mcg film ER (extended release), every 72 hours for pain; 11. Ambien, 5mg, 1 tablet, oral, once daily at bedtime as needed for insomnia (difficulty sleep); 12. Ipratropium’s Bromide and Albuterol Sulfate 0.5mg/3mg/3ml, 1 unit, via mask, every 4 hours as needed for shortness of breath/wheezing (breathing with a whistling or rattling sound in the chest)/congestion; 13. Lorazepam (Ativan), 0.5mg, 1 tablet, oral, every 2 hours as needed for anxiety/dyspnea (difficulty breathing). A review of the facility’s Medication Administration Record (MAR) dated 5/28, 5/29, 5/30 and 5/31/2022, indicated Patient 1 received: 1. 4 doses of Benazepril, 20 milligrams (mg, unit of measurement). 2. 4 doses of clonidine, 0.1mg. 3. 4 doses of Glipizide, 5mg. 4. 4 doses of Hydrochlorothiazide, 12.5mg. 5. 4 doses of Isosorbide Mononitrate, 30mg. 6. 4 doses of Januvia, 25mg. 7. 4 doses of Lasix, 20mg. 8. 4 doses of Levothyroxine, 100mg. 9. 4 doses of Memantine, 5mg. 10. 4 doses of Plavix, 75mg. 11. 4 doses of Pravastatin Sodium, 40mg. 12. 8 doses of FeroSul, 325mg. 13. 8 does of Pepcid, 20mg. 14. 4 doses of Ambien, 5mg. 15. 4 doses of Flomax, 0.4mg. 16. 11 doses of Ativan, 0.5mg as needed for anxiety. 17. 9 doses of Percocet 7.5-325mg as needed for pain. 15. 1 patch of Fentanyl Patch 72-hour 50mcg/hour (hr) on 5/28/2022. A review of Patient 1’s closed medical record (paper pack) provided by the DON on 8/3/22, indicated there was Patient 2’s medication list (list 2) inside Patient 1’s closed medical record. A review of List 2 indicated Patient 2 was prescribed: 1. Acetaminophen Suppository, 650mg, inserted rectally, every 4 hours as needed for pain/temperature greater than 100 Fahrenheit (F); 2. Ambien tablet, 5mg, 1 capsule, oral, at bedtime for insomnia; 3. Benazepril HCI, 20mg, 1 tablet, oral, twice daily for hypertension, increased blood pressure; 4. Bisacodyl Suppository, 10mg, insert rectally, 1 daily if no bowel movement for 3 days every 24 hours as needed for constipation; 5. Clonidine tablet, 0.1mg, 1 tablet oral, one time a day for hypertension; 6. Ferosul, tablet 325mg, 1 tablet by mouth, two times a day for supplement; 7. Flomax, 0.4mg, 1 capsule, oral, daily for enlarged prostate gland; 8. Glipizide tablet, 5mg, 1 tablet, oral, daily for hyperglycemia (increased blood sugar); 9. Hydrochlorothiazide, 12.5mg, 1 tablet, oral, daily for fluid retention; 10. Hyoscyamine, 0.125mg, 1 tablet, oral/sublingual (under tongue,) every 4 hours as needed for increase secretions; 11. Isosorbide Mononitrate, 30mg ER (extended release), 1 tablet, oral, daily for hypertension; 12, Januvia, 25mg, 1 tablet, oral, daily for hyperglycemia; 13. Lasix, 20mg, 1 tablet, oral, daily for fluid retention; 14. Levothyroxine, 100mcg, 1 tablet, oral, daily for hypothyroidism (a condition where the thyroid doesn’t create and release enough thyroid hormone into your bloodstream); 15. Lorazepam (Ativan) 0.5mg 1 tablet oral every 2 hours as needed for anxiety/shortness of breath); 16. Memantine HCI 5mg tablet 1 tablet oral daily for Alzheimer’s (a brain disorder that slowly destroys memory and thinking skills); 17. Pepcid, 20mg, 1 tablet, oral, two times a day for GERD (gastroesophageal reflux disease, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach causing burning sensation); 18. Plavix, 75mg, 1 tablet, oral, daily for anticoagulant (medicines that help prevent blood clots); 19. Pravastatin, 40mg, 1 tablet, oral, daily for HLD (hyperlipidemia, too much fat in the blood); 20. Zofran, 4mg, 1 tablet, oral, 8 hours as needed for nausea/vomiting; 21. Ipratropium Bromide and Albuterol Sulfate 0.5mg/3mg/3ml, 1 unit, via mask, every 4 hours as needed for shortness of breath/wheezing (breathing with a whistling or rattling sound in the chest)/congestion; 22. Morphine Sulfate IR (immediate release) 20mg/ml 0.25ml oral every 2 hours as needed for breakthrough pain/short of breath). During an interview on 8/3/2022 at 11:20 am, Licensed Vocational Nurse 2 (LVN 2) stated she was taking care of two hospice patients on 8/3/2022. LVN 2 stated when hospice transferring a patient to the facility, hospice nurse would come to the facility upon admission and hand over the patient’s medication list to the facility’s nurses. LVN 2 stated if the hospice nurses were not at the facility, they would fax the patient’s medication list to the facility. The facility’s admission nurse would enter the patient’s medication list into the facility’s PCC system after checking the lists for accuracy. LVN 2 stated if the facility staff had a question about the medication list, they needed to call the hospice physician for clarification. LVN 2 stated if the facility’s staff did not have a concern, staff would not call the hospice physician to verify the Physician Admission Orders. LVN 2 stated Hospice agency managed its patients’ care, and facility staffs just follow orders for the hospice physician. During an interview on 8/3/2022 at 11:40am, RN 1 stated upon admitting a hospice patient to the facility, the facility staff would review the physician order including medication list from the hospice agency or actual medications brought from the patient’s home. RN 1 stated the facility’s staff would page the hospice physician to verify the orders. RN 1 stated staff would verify order before administering any medications. RN 1 stated if the hospice nurse onsite upon patient’s admission and gave the medication list to facility’s staff in person, facility’s staff would just verify order with the hospice nurse onsite without calling the hospice physician for verification. RN 1 stated she was working on 5/27/2022 when Patient 1 was admitted to the facility. RN 1 stated HN 1 was onsite in the facility to admit Patient 1. RN 1 stated HN 1 handed her some papers including a medication list (list 2), HN 1 told RN 1 “don’t worry, our pharmacy will send you medications.” During an interview and concurrent review of Patient 1’s closed record on 8/3/2022, at 12:50 pm, the DON stated HN 1 was at the facility when Patient 1 was admitted on 5/27/2022 around 2 pm. The DON stated HN 1 provided the facility a medication list (List 2) for Patient 1. A concurrent review of medication list 2 indicated List 2 had Patient 2’s name on it. The DON stated RN 1 did not check the patient’s name (Patient 2) on List 2 and transcribed medications on List 2 into the facility’s PCC system under Patient 1’s. The DON pointed at List 2 and stated, “this list did not belong to Patient 1, it was Patient 2’s medication list.” The DON stated, “we made a mistake here, my nurse (RN 1) did not check the patient’s name on the medication list from hospice nurse before entering medications from the list into the facility’s PCC system.” The DON stated the wrong medications were given to Patient 1 during his 4 days stay in this facility. The DON stated after receiving any medication order, nurses need check the order for the patient’s name, birthday, and allergies. During an interview and concurrent review of Patient 2’s Physician Order (List 2), on 8/3/2022 at 1:30pm, RN 1 stated that she was the nurse transcribed the medication list for Patient 1 upon the patient’s admission to the facility’s PCC system. RN 1 stated HN 1 handed over preprinted medication list (List 2) for Patient 1. RN 1 stated she did not realize the medication list (List 2) received from