Health inspection·April 26, 2024

F760 Significant Med Error The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. 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 3/11/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the Recertification Survey. 1.The facility failed to maintain a medication error rate of less than 5 % (percent) during medication pass for Residents 53 by failing to: -Ensure Resident 53 was administered the entire dose of each medication per physician’s order. -Ensure facility staff administered medications within 60 minutes of the scheduled time, per facility policy and procedures (P&P) titled, "Medication Administration-General Guidelines.” -Implement the facility (P&P) titled, "Medication Administration-General Guidelines," updated 11/2021 to have sufficient staff and a medication distribution system to ensure safe administration of medications. "Medication Administration-General Guidelines." As a result, on 3/12/2024, there were five medication errors out of 25 opportunities resulting in a medication error rate of 20 percent (%), which placed Resident 53 at risk for decreasing therapeutic effects, worsening in medical conditions, hospitalization and/or death. 2.The facility failed to ensure Resident 135 and Resident 1 were free from significant medication errors by administering medications that were stored in unstable refrigerator temperatures from the Subacute refrigerator on Nursing Station 2 between 3/11/2024 to 3/13/2024. -Resident 135 was documented to have been administered 11 doses of Vancomycin (an antibiotic to treat infection) solution and two doses of Epogen (also known as Retacrit and Procrit, a glycoprotein [proteins with a sugar attached] that stimulates red blood cell production) between 3/11/2024 to 3/13/2024. -Resident 1 was documented to have been administered eight doses of Gabapentin (a medication that can be used for neuropathy [a condition where there is damage to the nerves] or seizures [sudden, uncontrolled burst of electrical activity in the brain]) and two doses of Epogen between 3/11/2024 to 3/13/2024. As a result, Resident 135 and Resident 1 were at an increased risk for adverse reactions (harmful and undesired effect), exposure to contaminated or deteriorated medications, and/or medications not stored in accordance with manufacturer's specification to maintain effectiveness and potency to treat the condition for which the medication was prescribed. a.A review of Resident 53's Admission Record indicated the facility readmitted the resident on 11/21/2023 with diagnoses including diastolic (the pressure in blood vessels between beats, when the heart is at rest) Congestive Heart Failure (CHF, a condition in which the heart's main pumping chamber, left ventricle, becomes stiff and unable to fill properly), asthma (difficulty breathing), systolic (left ventricle loses its ability to contract normally) Congestive Heart Failure, hypertension (high blood pressure), and cardiomegaly (an enlargement of the heart). A review of the Adverse Reaction related to Polypharmacy Care Plan dated 11/22/2023 indicated the goal for Resident 53 was to be free of adverse reactions. The care plan intervention indicated to review the resident’s medications for proper dosing, timing, and frequency of administration. According to another care plan dated 11/22/2023, Resident 53 was admitted to the facility with multiple medications and the care plan goal indicated to adhere to medications as ordered. The care plan intervention also indicated to administer the medications as ordered. A review of Resident 53's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 1/25/2024, indicated Resident 53 had intact cognition (thought process), required supervision for eating and substantial to maximal assistance from facility staff for activities of daily living. A review of the Physician's Order Summary Report, dated 3/12/2024, included: -Diltiazem Hydrochloride Extended-release (HCL ER, treats high blood pressure and prevents chest pain) capsules, 120 milligrams (mg, unit of weight), order date, 11/21/2023, by mouth one time a day for hypertension. Hold if SBP (Systolic Blood Pressure, measures the pressure in the arteries [carry blood away from the heart] when the heart beats) less than (<) 100 millimeters of mercury (mmHg, a measurement of pressure). Hold if HR (Heart Rate, the number of times the heart beats per minute [bpm]) less than (<) 60 bpm. -Metolazone (treats high blood pressure and fluid retention) 5 mg, order date, 11/21/2023, give one tablet by mouth one time a day for CHF. -Spironolactone (treats high blood pressure) 50 mg, order date, 11/21/2023, give one tablet by mouth on time a day for CHF. -Megestrol Acetated (used to treat loss of appetite and weight loss) oral suspension 400 mg/ 10 milliliter (ml, unit of volume), order date 11/21/2023, 10 ml (400 mg) by mouth two times a day for appetite stimulant. -Famotidine (reduces the amount of acid in the stomach) 40 mg, order date 11/21/2023, by mouth one time a day for gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting the mouth and stomach). -Wixela Inhub (fluticasone propionate 500 micrograms [mcg], salmeterol 50 mcg) inhalation aerosol powder breath activated combination medication, order date 11/21/2023, one inhalation two times a day for asthma, rinse mouth after use. -Cholecalciferol (Vitamin D, supplement) 25 mcg, order date 11/21/2023, by mouth one time a day for supplement. -Multivitamin with minerals (supplement), order date 11/21/2023, one tablet by mouth one time a day for supplement. During a concurrent observation and interview on 3/12/2024, between 10:50 AM through 11:16 AM, with Licensed Vocational Nurse (LVN) 6 at Nursing Station 4, Med cart 1, the following was observed during medication pass: -At 10:57 AM, LVN 6 began preparing Resident 53's scheduled 9 AM medications. -At 11:07 AM, LVN 6 stated she prepared eight morning medications for Resident 53 which included: Multivitamins with Mineral, one tablet, crushed and mixed with applesauce. Vitamin D 25 mcg, one tablet, crushed and mixed with applesauce. Wixela Inhub, oral inhaler. Diltiazem 24 Hour ER, 120 mg, one capsule, opened and mixed with applesauce. Spironolactone 50 mg, one tablet, crushed and mixed with applesauce. Famotidine 40 mg, one tablet, crushed and mixed with applesauce. Metolazone 5 mg, one tablet, crushed and mixed with applesauce. Megestrol Oral Suspension 40 mg/ml, 10 ml. At 11:13 AM, LVN 6 entered Resident 53's room and administered the prepared medications by mouth to the resident, using a spoon to scoop out most of the medications, leaving some medication behind in the medication cups. During a concurrent observation and interview, on 3/12/2024, at 11:18 AM, LVN 6 stated she completed the medication administration for Resident 53. LVN 6 was asked about the medication observed remaining inside of the medication cups. LVN 6 stated Resident 53 was not administered 100 % of the medications. LVN 6 stated if Resident 53 did not receive the full dosages of the medications the medications may not have been effective enough to treat the resident's conditions, such as controlling or reducing the resident's blood pressure. LVN 6 stated the resident should have received the full dose of each medication. LVN 6 reviewed the medication cups and stated the following medications had not been fully administered to Resident 53: Diltiazem 24 Hour ER, 120 mg Spironolactone 50 mg Famotidine 40 mg Metolazone 5 mg Megestrol Oral Suspension 40 mg/10 ml During an interview on 3/12/2024, at 11:26 AM, LVN 6 stated she usually finished passing morning medications pass by 10 AM. LVN 6 acknowledged that Resident 53 was administered her medications over two hours after the 9 AM scheduled administration time. LVN 6 stated morning medication pass was interrupted due to having to help the facility's wound care doctor and as a result the medication pass was started late. LVN 6 stated medications were supposed to be passed one hour (60 minutes) prior and up to one hour after the scheduled administration time. During a concurrent interview and record review on 3/12/2024, at 11:57 AM with RN 2, Resident 53's clinical record was reviewed. RN 2 reviewed Resident 53's nursing progress notes and stated there was no documentation in the nursing progress notes of a late medication administration and no documentation that Resident 53's doctor was called on 3/12/2024 regarding the late medication administration. On 3/13/2024, at 11:34 AM, during an interview, RN 2 stated that LVN 6 did not talk with RN 2 on 3/12/2024 to report any concerns that may have caused LVN 6 to be late passing morning medications. RN 2 stated there were two charge nurses (LVNs) on the floor and if the medication nurse (LVN 6) was having problems passing medications, the LVN could have asked the RN Supervisor, Director of Nursing, or other licensed nurses for help. RN 2 stated the facility had a treatment nurse that could help the wound care doctor. RN 2 stated if the medication administration time was 9 AM the nurse could administer the medications between 8 AM to 10 AM, and that administering medications scheduled for 9 AM at 11 AM was outside of the window to administer morning medications. RN 2 stated LVN 6 should have informed Resident 53's doctor the medications were administered late to make sure the resident was in stable condition and LVN 6 had to document that the doctor was informed. During an interview on 3/13/2024, at 11:40 AM, Registered Nurse (RN) 2 stated the medication nurse had to make sure all the medication were scooped out of the medication cup and administered to the resident. RN 2 stated that applesauce served as a binder and LVN 6 should have been able to scoop all the medications out when mixed with the applesauce. RN 2 stated licensed nurses must follow the rights of medication administration that included, the right patient, right drug (medication), right dose, and right time. b. During a concurrent interview and medication area inspection on 3/13/2024, at 12:12 PM, with Registered Nurse (RN) 2 of the medication room's refrigerator located on Nursing Station 2, RN 2 unlocked and opened the Subacute refrigerator, reviewed the thermometer located on the door inside of the refrigerator and stated the temperature was 50 degrees (°) Fahrenheit ([F], a standard scale used to measure temperature). RN 2 stated the refrigerator temperature should be less than 46°F. RN 2 stated the refrigerator temperature range for medication storage should be between 36°F to 46°F. During a concurrent observation and interview on 3/13/2024, at 12:36 PM, in the presence of RN 1 and Maintenance Director (MAINT) 1, the Subacute Refrigerator temperature was rechecked by MAINT 1 using an UEI infrared thermometer. MAINT 1 stated the Subacute refrigerator temperature reading was 48.1°F inside of the refrigerator (above normal). During an interview on 3/13/204, at 4:29 PM, RN 2 stated residents had the potential to be exposed to deteriorated medications when administered medication that was stored in the Subacute refrigerator when the temperature was out of range (when stored outside of 36°F to 46°F parameter). On 3/13/2024, at 4:40 PM, during a concurrent review of the facility's maintenance log on Nursing Station 2 and interview in the presence of RN 2, with a Licensed Vocational Nurse (LVN) 3, the maintenance log was reviewed, dated 3/11/2024 and timed at 12:15 PM, documented, "check subacute med fridge temp high." LVN 3 stated the Subacute refrigerator temperature was high (above normal) two days ago on 3/11/2024, and she reported the high temperature to maintenance. LVN 3 stated she did not document what the high temperature reading was but should have. During a concurrent interview and review of the facility's maintenance log on Nursing Station 2, on 3/13/2024, at 4:46 PM, MAINT 1 stated LVN 3 reported the refrigerator for subacute was out of range on Monday, 3/11/2024. MAINT 1 stated he did not follow-up to make sure the Subacute refrigerator temperature was stable and was in good working order and should have. The subacute refrigerator temperature was readings on 3/13/2024 were as follows: 12:16 PM temperature 50°F - manual thermometer by RN 1 12:27 PM temperature 48°F - manual thermometer by RN 2 12:36 PM temperature betw. 48.1°F F to 58°F by MAINT 1 with UEI Infrared temperature gun 6:05 PM temperature 54°F - manual thermometer by RN 2. A review of Resident 135's Admission Record indicated the resident was admitted to the facility on 9/26/2023 with diagnoses that included hypertension (high blood pressure), acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in your body), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), generalized muscle weakness (lack of muscle strength requiring extra effort to move), and anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues). A review of the MDS, dated 12/28/2023, indicated Resident 135 was rarely or never understood and was dependent upon facility staff for activities of daily living. A review of Resident 135's Physician’s Order Summary Report with active orders as of 3/13/2024, indicated: -Vancomycin 125 mg (2.5 ml) via gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition and/or medication directly to the stomach) every six hours for C. diff (also known as Clostridium difficile, a bacterium [germ] that can infect the bowel and cause diarrhea), order date 3/5/2024. According to manufacturer labeling indicated to shake the reconstituted solutions of Vancomycin hydrochloride for oral solution well before each use and to use an oral dosing device that measures the appropriate volume of the oral solution in milliliters. Store the reconstituted solutions of Vancomycin hydrochloride for oral solution at refrigerated conditions 2°Celsius (C, unit of temperature to 8°C) (36°F to 46°F) when not in use. Discard reconstituted solutions of Vancomycin hydrochloride for oral solution after 14 days, or if it appears hazy or contains particulates. -Epogen Injection Solution 3000 units/ml, inject subcutaneously ([SQ] just under the skin) one time a day every Monday, Wednesday, and Friday related to anemia, rotate injection site, order date 3/7/2024 According to manufacturer indicated, store Epogen in the refrigerator between 36°F to 46°F. Keep Epogen away from light. Single-dose vials of Epogen should be used only one time. Throw the vial away after use even if there is medicine left in the vial. During a concurrent interview and review of Resident 135's Medication Administration Record (MAR), on 3/13/2024, at 6:11 PM with RN 2, Resident 135's MAR was reviewed between 3/11 to 3/13/2024. The MAR indicated Vancomycin 11 doses were administered (four doses on 3/11/24, five doses on 3/12/24, and two dose on 3/13/2024) and two doses of Epogen were administered, one dose on 3/11/2024 and one dose on 3/13/2024. RN 2 stated adverse effects of Vancomycin could include, Redman Syndrome, generalized redness of the resident, and would need to monitor the resident for shortness of breath. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 3/1/2021 with diagnoses that included anemia, epilepsy (seizures, a disorder in which nerve cell activity in the brain is disturbed), and polyneuropathy (when multiple peripheral nerves [nerves outside the brain and spinal cord] become dama