Health inspection·May 6, 2022

Title 22 § 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. § 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code. F609 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. On 2/18/2022 at 11:28 am, an unannounced visit was made to the facility to investigate missing narcotics (group of medications that are controlled substances due to have a high potential for abuse which may lead to severe psychological or physical dependence) for Patient 1. The facility failed report to California Department of Public Health (CDPH) missing narcotics for Patient 1, who was under hospice care (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life), within 24 hours. This deficient practice had the potential for the patient to not receive (pain relieving) medication on time and at risk for diversion (prescription medicines are obtained or used illegally) of narcotics. During an interview on 2/18/2022 at 11:38 am, the Director of Nursing (DON) stated the evening shift (3 pm to 11 pm) nurse called him (on 1/27/22) informing him of missing Morphine Sulfate (a controlled substance used to treat severe pain) medication for Patient 1. A review of Patient 1's Admission Record indicated the patient was admitted to the facility on 12/07/2021 with diagnoses that included multiple myeloma (abnormal plasma cells that build up in the bone marrow and form tumors in many bones of the body) and Chronic Obstructive Pulmonary Disease (COPD, disease that cause airflow blockage and breathing related problems). A review of Patient 1's physician order, dated 12/31/2021, indicated to admit the patient under hospice care. A review of Patient 1's physician order, dated 1/27/2022, indicated an order for the patient to receive Morphine Sulfate 15 milligram (mg, a unit of measurement for weight) give 1 tablet by mouth (PO) three times a day (TID) for pain management. A review of Patient 1's progress notes, dated 1/27/2022 at 21:57 (9:57 pm), indicated that Morphine Sulfate Tablet 15 mg was ordered to be given 1 tablet TID for pain management and that the medication was not in the facility. Licensed Vocational Nurse 2 (LVN 2) called the pharmacy to have the prescription delivered. During a telephone interview on 2/18/2022 at 12:44 pm, LVN 2 stated that when he checked Patient 1's electronic Medication Administration Record (eMAR), he noticed that there was a scheduled medication for Morphine Sulfate. LVN 2 stated that he checked the medication cart and the morphine bubble pack was not there. LVN 2 also stated that Patient 1 did not have a narcotic count sheet for Morphine Sulfate. LVN 2 stated that he called DON and the hospice agency to request for a refill for Morphine. A review of Patient 1's eMAR for January 2022, indicated that Morphine Sulfate 15 mg 1 tab TID (scheduled for 6 am, 2 pm, and 10 pm) was discontinued on 1/27/2022 at 1743 (5:43 pm) and the patient last received morphine on 1/27/2022 at 6 am (2 pm dose not administered). A review of Patient 1's eMAR for January 2022, indicated that Morphine sulfate 15 mg 1 tab three times a day for pain was re-started on 1/27/2022 at 10 pm and the patient received morphine at 10 pm. During an interview on 2/18/2022 at 11:38 am, DON stated that he called the hospice agency to request a refill for the missing Morphine Sulfate medication (bubble pack). The DON stated that the Morphine bubble pack and the count sheet were both missing. The DON stated that he did not report the incident to CDPH. A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting," revised on 8/2012, indicated unusual occurrences were reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility failed report to CDPH missing narcotics (group of medications that are controlled substances due to have a high potential for abuse which may lead to severe psychological or physical dependence) for Patient 1, who was under hospice care (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life), within 24 hours. This deficient practice had the potential for the patient to not receive (pain relieving) medication on time and at risk for diversion (prescription medicines are obtained or used illegally) of narcotics. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients.