Other·March 19, 2024

F684 Title 42 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following Title 22 CCR § 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. (c) The time and dose of the drug or treatment administered to the patient shall be recorded in the patient's individual medication record by the person who administers the drug or treatment. Recording shall include the date, the time and the dosage of the medication or type of the treatment. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record. Title 22 CCR § 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 2/3/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility, for an annual recertification survey. The facility failed to: 1. Follow its policy and procedure tiled, "Administering Medications," which indicated required medications were administered in a safe and timely manner and as prescribed within one hour before or after, of their prescribed/scheduled time. 2. Ensure its medication error rate was less than five percent ([%] unit of measurement). Sixty-four medication errors out of 82 total opportunities contributed to an overall medication error rate of 78 % affecting 17 out of 20 residents observed during medication administration (Residents 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99). The medication errors were as follows: a. Omitted and/or late administration of Amiloride HCI (medication to treat high blood pressure) 10 milligram ([mg] unit of measurement) for hypertension ([HTN] high blood pressure), of Finasteride (medication to treat overgrowth of prostate) 5.0 mg for benign prostatic hyperplasia ([BPH] a condition when the prostate [male organ] and surrounding tissue expands), Namenda (medication to treat Alzheimer's [a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) 10 mg for Alzheimer's disease to Resident 1. b. Omitted and/or late administration of Acetazolamide (medication to treat glaucoma) 500 mg, Benztropine Mesylate (medication to help body fight infections) 0.5 mg for immunodeficiency (failure of the immune system to protect the body adequately from infection), Risperdal (medication used to treat schizophrenia) 2 mg, Propranolol HCI (medication to treat high blood pressure) 20 mg, Aspirin (medication used to prevent interruption of blood flow to the cells of the brain) 81 mg for prophylaxis (measures designed to preserve health and prevent the spread of disease) of cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain) to Resident 2 . c. Omitted and/or late administration of Metformin (medication to treat high blood sugar) 500 mg to Resident 3. d. Omitted and/or late administration of Vascepa (medication to treat high cholesterol) 1.0 gm two capsules for hyperlipidemia, Amantadine HCl (medication to treat involuntary, erratic, twisting movements of the face, arms, legs or trunk) 100 mg for dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk) Lamotrigine (medication used to treat bipolar disorder [a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows] and schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions]) 400 mg, Trihexyphenidyl HCL (medication given to treat Extrapyramidal side effects [EPS], commonly referred to as drug-induced movement disorders) 3.0 gm ([gram] unit of measurement) and Flomax (medication to treat overgrowth of prostate [BPH]) 0.4 mg to Resident 4. e. Omitted and/or late administration to Resident 6 of Midodrine (for low blood pressure) 5 mg, Keppra ([Levetiracetam] medication to treat seizure [a sudden, uncontrolled burst of electrical activity in the brain] disorder) 5.0 milliliters ([ml] unit of measurement) of 100 mg/ml for seizure disorder, Gabapentin (medication used to treat nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) 300 mg for neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) to Resident 6. f. Omitted and/or late administration of Symbicort inhalation aerosol (medication used to treat [{Asthma} a condition when airways in the lungs become narrowed and swollen, making it difficult to breathe]) 160- 4.5 mg one puff, Norvasc (medication used to treat hypertension) 10 mg HTN, Eliquis (medication to treat damaged tissues in the brain due to a loss of oxygen to the area) 5 mg, Metoprolol Tartrate (medication to treat HTN) 25 mg for HTN, and Losartan Potassium (medication to treat HTN) 25 mg for HTN to Resident 8. g. Omitted and/or late administration of Zyprexa ([Olanzapine] medication given to treat hallucinations in mental disorder) 7.5 mg tablet for auditory hallucinations (hearing voices or noises that do not exist in reality) related to schizophrenia and Metformin HCL 500 mg tablet for DM to Resident 14. h. Omitted and/or late administration to Resident 15 of Cogentin (medication given to treat EPS) 1.0 mg for EPS, Risperdal (medication to treat schizophrenia)1.0 mg, Metformin HCL 850 mg for diabetes mellitus ([DM] a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Lactulose (medication used to treat elevated ammonia levels[high ammonia levels can cause permanent brain damage, coma, and even death]) 15 ml of 10 gm/15 ml for elevated ammonia levels, and Admelog Solution ([Insulin Lispro] medication used to treat elevated blood sugar) 100 units/ml subcutaneously ([SQ] beneath, or under, all the layers of the skin) to Resident 15. i. Omitted and/or late administration of Cogentin 1.0 mg for EPS, Amlodipine Besylate (medication used to treat HTN) 10 mg for HTN, Aspirin 81 mg for CVA prophylaxis, Levetiracetam 10 ml of 500 mg/5 ml for epilepsy (a recurrent seizures, which are brief episodes of involuntary movement that may involve a part of the body or the entire body), Topiramate (medication used to treat seizures) 100 mg for seizure, and Haloperidol (a medication to treat schizophrenia) 1.0 mg for schizophrenia to Resident 16. j. Omitted and/or late administration of Fluoxetine HCL (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) 10 mg and Levetiracetam 5 ml of 100mg/ml for convulsions to Resident 18. k. Omitted and/or late administration of Carvedilol (medication used to treat high blood pressure) 6.25 mg for HTN, Duloxetine HCl (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) 60 mg for major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Amlodipine Besylate 10 mg for HTN, and Aspirin 81 mg for CVA prophylaxis to Resident 22. l. Omitted and/or late administration of Amlodipine Besylate 10 mg for HTN and Benazepril HCl (medication used to treat high blood pressure) 40 mg for HTN to Resident 25. m. Omission of late administration of Duloxetine HCl 40 mg low mood and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), Baclofen (medication used to treat muscle spasms [an involuntary and abnormal muscular contraction]) 10 mg for muscle spasms, Amlodipine Besylate 5 mg tablet for HTN, Gabapentin 400 mg for neuropathy, and Keppra 500 mg for seizure to Resident 26. n. Omitted and/or late administration of Lasix (diuretic) 60 mg for heart failure (condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), Gabapentin 600 mg, Metformin HCl 1000 mg for diabetes mellitus (DM), Carvedilol 6.25 mg for HTN, Benazepril HCL 40 mg HTN, Clonidine (medication used to treat high blood pressure) 0.2 mg for HTN, and Empagliflozin (medication used to treat high blood sugars) 10 mg for DM to Resident 26. o. Omitted and/or late administration of Norvasc 5 mg for HTN, Seroquel (medication used for the treatment of schizophrenia) 37.5 mg for bipolar disorder, and Aspirin 81 mg for CVA prophylaxis to Resident 38. p. Omitted and/or late administration of Topamax (medication used to treat seizure) 100 mg for seizure, Lacosamide (medication used to treat seizures) 100 mg for seizure, Keppra 750 mg for seizure, Lisinopril (medication used to treat abnormally high blood pressure) 20 mg for HTN, Cymbalta (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) delayed release capsule 30 mg, Sinemet (medication used to treat Parkinson's disease [a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves]) 10 mg of 10-100 mg for Parkinson's disease, Aspirin 81 mg for CVA prophylaxis, Cenobamate (medication given to treat seizures) 50 mg for seizure, and Baclofen 10 mg for muscle spasm to Resident 44. q. Omitted and/or late administration of Morphine Sulfate (narcotic medication used to treat pain) 15 mg for pain to Resident 99. As a result, Residents 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99 were at risk for serious medical complications such as stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hyperglycemia (an excess of sugar in the bloodstream), diabetic coma (a life-threatening disorder that causes unconsciousness), uncontrolled seizure, worsening of depression, anxiety, schizophrenia and death. 1. During a review of Resident 1's Face Sheet (admission record), dated 2/4/2024, the face sheet indicated Resident 1 was admitted to the facility on 6/24/2015 and readmitted on 9/25/2017 with diagnosis including Alzheimer's Disease, HTN, and BPH. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/11/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 1 had medically complex conditions and was receiving antipsychotic and antidepressant medications. During a review of Resident 1's physician's order dated 6/30/2023, the physician's order indicated an order for Amiloride HCI 5.0 mg to administer two tablets (10 mg) for hypertension, the order dated 3/19/2019 for Finasteride (medication to treat overgrowth of prostate) 5.0 mg give one tablet daily for BPH, and the order for Namenda 10 mg one tablet daily for Alzheimer's disease. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., the licensed vocational nurse (LVN 2) did not administer to Resident 1 Amiloride HCI 10 mg, Finasteride 5 mg, and Namenda 10 mg at 7:30 a.m., as scheduled. During a review of Resident 1's Medication Administration Record (MAR) dated 2/3/2024, the MAR indicated medication Amiloride HCI 10 mg was administered on the same day 2/3/24 at 12:09 p.m., instead as scheduled at 7:30 a.m., and Finasteride 5 mg and Amenda 10 mg were administered on 2/3/24 at 12:10 a.m., which was approximately 4.0 hours and 40 minutes later than scheduled time. 2. During a review of Resident 2's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 2 was admitted to the facility on 4/21/2018 with diagnosis including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interaction), immunodeficiency, glaucomatous flecks (subcapsular [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve]) both eyes, and HTN. During a review of Resident 2's MDS, dated 11/3/2023, the MDS indicated Resident 2 was able to understand and be understood by others and his vision was severely impaired. The MDS Section N0415 High-Risk Drug Classes indicated Resident 2 had medically complex conditions and was receiving antipsychotic and antiplatelet medication (a group of medicines that stop blood cells (called platelets) from sticking together and forming a blood clot). During a review of Resident 2's physician's order dated 3/12/2019, the physician's order indicated an order for Acetazolamide 500 mg by mouth twice a day for glaucoma, the order dated 8/4/2021 for Benztropine Mesylate 0.5 mg tablet twice a day for immunodeficiency, the order dated 10/24/2022 for Risperdal 2 mg by mouth in the morning for mood swings related to schizophrenia, the order date 2/4/2021 for Propranolol HCI 20 mg tablet twice a day for HTN, and the order dated 7/31/2023 for Aspirin (medication used to prevent interruption of blood flow to the cells of the brain) 81 mg tablet by mouth once a day in the morning for prophylaxis (measures designed to preserve health and prevent the spread of disease) of cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain). During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering to Resident 2 Acetazolamide 500 mg one tablet, Benztropine Mesylate 0.5 mg one tablet and Risperdal 2.0 mg two tablets as scheduled at 7:30 a.m. During a review of Resident 2's MAR dated 2/3/2024, the MAR indicated medication Acetazolamide 500 mg one tablet, Benztropine Mesylate 0.5 mg one tablet and Risperdal 2.0 mg two tablets were administered on 2/3/24 at 12:03 p.m.., which was approximately 4.0 hours and 30 minutes later than scheduled time. 3. During a review of Resident 3's Face Sheet (Admission Record), dated 2/4/2024, the face sheet indicated Resident 3 was admitted to the facility on 11/24/2010 with diagnosis including type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. During a review of Resident 3's MDS, dated 11/3/2023, the MDS indicated Resident 3 usually was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 3 had medically complex conditions and was receiving hypoglycemic medication (a medication to lower blood sugar level). range). During a review of Resident 3's physician's order dated 6/30/2023, the physician's order indicated the order for Metformin (medication to treat high blood sugar) 500 mg one tablet twice a day for diabetes. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Metformin 500 mg one tablet to Resident 3 for diabetes as scheduled at 7:30 a.m. During a review of Resident 3's MAR dated 2/3/2024, the MAR indicated medication Metformin 500 mg one tablet was administered on 2/3/24 at 11:11 a.m., which was approximately 3.0 hours and 40 minutes later than scheduled time. 4. During a review of Resident 4's Face Sheet (Admission Record), dated 2/4/2024, the Face Sheet indicated Resident 4 was admitted to the facility on 5/26/2015 with diagnosis including hyperlipidemia (abnormally high concentration of fat particles [lipids] in the blood), schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly) and unspecified abnormal involuntary movements (occurs when you move yo