Health inspection·February 3, 2023

F760 The facility must ensure that its— §483.45(f)(2) Residents are free of any significant medication errors. § 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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 § 72353. Pharmaceutical Service - General. (b) Dispensing, labeling, storage and administration of drugs and biologicals shall be in conformance with state and federal laws. 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. The facility failed to monitor behavior for use of psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) as indicated on the physician order and ensure Patient 1 was free of any significant medication error due to missed and incorrect doses of prescribed psychotropic medications. This deficient practice resulted in the inconsistent monitoring of Patient 1’s behavior, which resulted in Patient 1 being transferred to the General Acute Care Hospital (GACH) and also due to exhibiting aggressive behavior and being a danger to self and others such as attempting to kick staff, cursing (use of offensive or impolite language), locking himself in the bathroom, and stating if he wanted to hurt himself, he would do it without telling staff. A review of the Admission Record indicated Patient 1 was admitted to the facility on 7/26/2022, with diagnoses of schizoaffective disorder (a mental illness that causes loss of contact with reality) bipolar (mental disorder characterized by episodes of mania and depression) type, manic (abnormally excited mood) episode, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), single episode, severe with psychotic features. A review of Patient 1's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 7/30/2022, indicated Patient 1 had cognitively intact (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Patient 1 did not exhibit any behavior or mood symptoms. The MDS indicated Patient 1 required extensive two or more people assistance (patient involved in activity, staff provide weight-bearing support) for bed mobility (how patient moves to and from lying position, turns side, and positions body while in bed or alternate sleep furniture) and transfer (how patient moves between surfaces including to or from bed, chair, wheelchair, standing position). The MDS indicated Patient 1 required total dependence (full staff performance) for locomotion on (how patient moves between locations in his/her room and adjacent corridor on same floor), locomotion off unit, toilet use, and personal hygiene. A record review of Patient 1's Clinical Notes, dated 10/19/2022 at 11:33 a.m., by Registered Nurse 2 (RN 2), indicated Patient 1 attempted to kick Certified Nurse Assistant 3 (CNA 3). The Clinical Notes indicated Patient 1 stated, "I bet I'll kiss and slap your ass that I won't fall." A record review of Patient 1's Clinical Notes, dated 10/19/2022 at 5:44 p.m., by Licensed Vocational Nurse 6 (LVN 6), indicated Patient 1 stated, "LVN 6 was a bitch." A record review of Patient 1's Clinical Notes, dated 10/20/2022 at 12:05 p.m., by the Director of Nursing (DON), indicated Patient 1 was extremely aggressive and continued to talk to himself. The Clinical Notes also indicated Patient 1 locked himself inside the bathroom in the morning and did not open the bathroom for the nurses. A record review of Patient 1's Clinical Notes, dated 10/20/2022 at 12:35 p.m., by the DON, indicated Patient 1 was sitting on the floor, very upset, and responded if he wanted to hurt himself, he would do it without telling anyone. A record review of the Discharge/Transfer Notice, dated 10/20/2022, indicated Patient 1 was transferred to GACH because he was a danger to himself and others. A record review of the GACH Emergency Room (ER) Discharge Summaries Notes, dated 10/24/2022, by PSY 1, indicated Patient 1 gesticulated (use of gestures) bizarre (strikingly unusual or odd) and hostile manner in attempted conversation engagement. The PSY 1's note indicated Patient 1 was not eating or drinking fluids and was transferred to the medical floor to provide intravenous (IV, an apparatus used to administer a fluid [as of medication, blood, or nutrients] hydration [process of causing something to absorb water]) and parental nutrition (IV administration of nutrition, which may include protein, carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements for patients who cannot eat or absorb enough food through tube feeding formula or mouth to main good nutrition status along with medication). The PSY 1's note also indicated Patient 1 showed no improvement while he was at the behavioral health department. During a telephone interview on 11/9/2022 at 9:08 a.m. with Family Member 1 (FM 1), FM 1 stated she paid very close attention to Patient 1's behavior and noticed a decline in Patient 1's behavior. FM 1 stated Patient 1 was irritated, more talkative, and noncooperative. FM 1 stated she notified PSY 2 of Patient 1's decline in behavior. FM 1 stated PSY 2 saw Patient 1 and also noticed a decline in his behavior. During a concurrent interview with LVN 1 and record review of the Electronic Medication Administration Report (e-MAR) on 11/9/2022 at 10:41 a.m., LVN 1 stated he gave Patient 1 Valproic Acid (a medication used to treat various types of seizure disorders [uncontrolled electrical disturbance in the brain] and manic episodes related to bipolar disorder) 5 milliliters (ml, a unit used in the metric system for measuring capacity) on 10/12/2022, 10/13/2022, and 10/14/2022 for the morning and noon medication pass. The physician order was to administer Valproic Acid 250 mg/5ml (500 mg) solution oral four times daily , ordered on 9/15/2022 During a concurrent interview with LVN 3 and record review of the e-MAR on 11/9/2022 at 3:29 p.m., LVN 3 stated she gave Patient 1 Valproic Acid 5 ml on the following dates and times: 1. 9/5/2022 for the morning (9 a.m.) medication pass 2. 9/6/2022, 9/7/2022, 9/14/2022 for the dinner (5p.m.) and bedtime (HS, 9p.m.) medication pass. 3. 9/15/2022 for the dinner medication pass LVN 3 stated she administered Olanzapine (an antipsychotic medication primarily used to manage psychosis [mental disorder characterized by a disconnection from reality]) 20 milligrams (mg, unit of measurement) on 10/5/2022, 10/6/2022, and 10/11/2022 at bedtime to Patient 1. The physician orders were to administer Valproic Acid 250 mg/5ml (500 mg) solution oral four times daily, ordered on 7/27/22 and to administer Olanzapine 25 mg tablet oral daily, ordered on 9/30/2022. During a concurrent interview with LVN 4 and record review of the e-MAR on 11/9/2022 at 4:05 p.m., LVN 4 stated she gave Patient 1 the following: 1. Valproic Acid 5 ml on 9/2/2022, 9/3/2022, 9/5/2022, 9/8/2022, 9/9/2022, 9/10/2022, 9/11/2022, 10/1/2022, 10/2/2022, 10/7/2022, 10/8/2022, and 10/10/2022 for the dinner and bedtime medication pass. 2. Olanzapine 20 mg on 10/1/2022, 10/2/2022, 10/7/2022, 10/8/2022, and 10/10/2022 for the bedtime medication pass. The physician orders were to administer Valproic Acid 250 mg/5ml (500 mg) solution oral four times daily, ordered on 7/27/22 and to administer Olanzapine 25 mg tablet oral daily, ordered on 9/30/2022. During an interview on 11/22/2022 at 3:29 p.m., LVN 3 stated Patient 1 was more pleasant before. LVN 3 stated Patient 1 was not smiling anymore. LVN 3 stated Patient 1 became darker (unhappy or sad, gloomy) . LVN 3 stated she noticed the change in Patient 1's behavior of not smiling and being more upset, a few weeks before he was transferred to GACH on 10/20/2022. LVN 3 stated Patient 1's physician was made aware of the change in Patient 1's behavior and gave an order to monitor Patient 1's behavior. During an interview on 11/22/2022 at 4:05 p.m., LVN 4 stated Patient 1 had a change in his behavior such as yelling at nothing and had outbursts on 10/19/2022 before he was hospitalized on 10/20/2022. During a telephone interview on 11/23/2022 at 11:12 a.m., the facility's Consultant Pharmacist (CPH) stated if Patient 1 received Valproic Acid 250 mg (5 ml) instead of the Valproic Acid 500 mg (10 ml) 4 times a day per doctor's order, Patient 1's behavior would not be controlled and Patient 1's mood behaviors would have manifested itself more. The CPH stated the doctor increased Olanzapine 20 mg to Olanzapine 25 mg on 9/30/2022 to address Patient 1's psychotic behavior. The CPH stated if Patient 1 received Olanzapine 20 mg instead of Olanzapine 25 mg daily per doctor's order, Patient 1's psychotic behavior would be manifested more, and Patient 1 would have more episodes of agitation. The CPH stated the Pharmacist who did the recap (to make or be able to make a summary) should have fixed how the medication was written and entered by the admitting nurse. The CPH stated the pharmacist should have clarified the Valproic Acid to make it 10 ml instead of 5 ml. The CPH stated the nurses should calculate the amount of Valproic Acid 500 mg solution ordered and should have given 10 ml because the doctor's order was Valproic Acid 250 mg/5 ml. The CPH stated it was not acceptable for the nurses to give less than what the doctor ordered for the medications. The CPH further stated the nurses were supposed to follow the doctor's orders. During a concurrent interview with the DON and record review of the e-MAR on 11/23/2022 at 12:53 p.m., the DON stated if the medications were not given per doctor's orders, the patient's behavior will not be controlled, and patient may develop previous behaviors of being aggressive, irritable, and talking to himself. The DON stated when the patient does not receive the correct dose of a psychotropic medication, this will cause a change in the patient’s behavior. The DON stated the Licensed Nurse's signature on the e-MAR indicated medication was administered to the patient. The DON stated the " = " on the e-MAR meant the nurses did not give the medication. The DON verified the following medications were not administered to Patient 1 according to the e-MAR: 1. For July 2022 Valproic Acid 500 mg - There was one missed dose (7/27/2022) 2. For September 2022 a. Valproic Acid 500 mg - There were 10 missed doses (9/4/22 dinner and HS, 9/5/22 noon, 9/12/22 dinner and HS, 9/16/22 HS, 9/25/22 dinner and HS, 9/27/22 dinner and HS). b. Quetiapine (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and depression) 200 mg tablet (2 tablets) by mouth once a day at bedtime for delusional thoughts manifested by talking to self, ordered 7/29/2022 - There were 5 missed doses (9/4/22, 9/12/22, 9/16/22, 9/25/22, and 9/27/22). 3. For October 2022 a. Valproic Acid 500 mg - There were 12 missed doses (10/3/22 dinner and HS, 10/4/22 dinner and HS, 10/9/22 dinner and HS, 10/16/22 dinner and HS, 10/17/22 dinner and HS, 10/18/22 dinner and HS. b. Quetiapine 200 mg (2 tabs) - There were six missed doses (10/3/22, 10/4/22, 10/9/22, 10/16/22, 10/17/22, and 10/18/22). c. Olanzapine 25 mg - There were 5 missed doses (10/3/22, 10/4/22, 10/9/22, 10/16/22, and 10/17/22). d. Olanzapine 30 mg - There was one missed dose (10/18/22 ) The DON stated there was no documentation indicating the reason why the following medications were not administered to Patient 1. The DON stated Patient 1 was observed talking to himself more than usual a week prior to hospitalization on 10/20/2022. During a concurrent interview with the DON and record review of the e-MAR on 11/23/2022 at 4:43 p.m., the DON stated when nurses administer medications, they sign the e-MAR. The DON stated the Medical Records Director reviews the e-MAR and would let the DON know if there were any missing signatures which would indicate medication was not administered. The DON stated she was not aware Patient 1 had missing medication doses for the months of July, September, and October. During a telephone interview on 12/5/2022 at 1:40 p.m., PSY 1 stated the facility was giving Patient 1 Valproic Acid 5 ml four times a day, when they should have been giving Patient 1 Valproic Acid 10 ml (500 mg) four times a day according to the Physician Order. The PSY 1 stated if Patient 1 received missed and incorrect doses of psychotropic drugs, Patient 1 would become manic and agitated when decompensated (the failure to generate effective psychological coping mechanisms in response to stress, resulting in personality disturbance or disintegration, especially that which causes relapse in schizophrenia). The PSY 1 stated Patient 1 would become very agitated, rambled, and would shut down when not receiving the correct dose of medication. The PSY 1 stated had witnessed Patient 1 had manic psychosis (severe mental disorder that causes abnormal thinking and perception) when he was admitted to GACH on 10/20/2022. A review of Patient 1's Physician Order for Anti-Psychotic Behavior Monitoring indicated as follows: a. Physician (MD) ordered on 7/26/2022 for physical monitoring of antipsychotic TCAP (T = tardive dyskinesia (facial, tongue movement); C = cognitive impairment (decreased mental status); A = akathisia (inability to sit still); P = parkinsonism (tremors, drooling, rigidity) side effects, behavior management interventions, behavior outcome, and behavior tally three times daily for Olanzapine. b. MD ordered on 9/15/2022 for physical monitoring of antipsychotic TCAP side effects, behavior management interventions, behavior outcome, and behavior tally three times daily for Quetiapine. c. MD ordered on 9/16/2022 for physical monitoring of antipsychotic TCAP side effects, behavior management interventions, behavior outcome, and behavior tally three times daily for Valproic Acid. During a concurrent interview with the DON and record review of Patient 1's Treatment Administration Record (TAR) on 12/7/2022 at 1:41 p.m., the DON stated nurses tally behavior (a record of each occurrence of behavior) to conclude when there is a change of behavior. The DON stated monthly behaviors of 15 or more would be of concern that would require a notification to the psychiatrist. The DON stated the charge nurse was responsible to monitor and tally the patient’s behavior. The DON stated she (DON) was responsible to review the monthly tally done by the nurses to see if the patients were stable or not. The DON stated she (DON) would inform the psychiatrist of the patients who needed to be seen based on the monthly tally report of the Psychotherapeutic Drug Summary Behavior Sheet. The DON stated nurses did not do Patient 1's behavior monitoring for Valproic Acid and Quetiapine for the month of July 2022 and August 2022. The DON stated the monthly Psychotherapeutic Drug Summary Behavior Sheet was not accurate because it did not have all the tallied numbers for each shift. The DON stated the TAR indicated Patient 1 neither received all antipsychotic behavior monitoring, nor was there