F0658

E

Failure to Follow Medication Guidelines, Change-of-Condition Monitoring, Care Planning, and Neuro Check Protocols

Eureka, California Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to administer medications according to professional standards and facility policy for one resident with hypothyroidism. The resident had physician orders for levothyroxine 88 mcg by mouth in the morning for hormone regulation and famotidine 20 mg by mouth in the morning for GERD. A medication regimen review dated 12/26/25 documented a pharmacist recommendation that famotidine could be given without regard to meals but should not be given at the same time as levothyroxine, and suggested changing famotidine administration time to 9 a.m. Review of the medication administration records from 12/21/25 to 1/29/26 showed both medications were administered together at 6 a.m. throughout this period. The consultant pharmacist confirmed that levothyroxine should not be given with other medications because it could bind with them and decrease effectiveness, and a licensed nurse also acknowledged that levothyroxine should not be given with other medications and that such an order should be clarified with the physician or pharmacist.

The deficiency also includes failure to complete required 72‑hour monitoring after a change of condition (COC) for two residents. One resident with hemiplegia, hemiparesis following cerebral infarction, diabetes mellitus, and intact cognition reported multiple episodes of diarrhea over several days, including at least three brief changes in one day and decreased oral intake due to diarrhea and upset stomach. An SBAR communication form documented that this resident reported five episodes of green, mucus-like diarrhea without foul odor, constituting a COC. Review of progress notes from the time of the COC through several days later showed that the resident was only monitored on two occasions, rather than every shift for 72 hours as required by the facility’s Change in Condition policy. The DON confirmed that no 72‑hour monitoring was completed on multiple shifts following this COC.

Another resident, admitted with fractures of the first cervical vertebra, left pubis, and multiple ribs and with moderately impaired cognition, experienced unwitnessed falls on two separate dates. Progress notes showed that following these COCs related to falls, the resident was monitored only on a limited number of dates and times, rather than each shift for at least 72 hours as required by policy. The DON confirmed that 72‑hour monitoring was not completed on specified shifts after the first fall and that the resident fell again several days later, after which 72‑hour monitoring was again not completed on certain shifts. The facility’s Change in Condition policy required the licensed nurse to update the care plan to reflect the resident’s current status and to document each shift for at least 72 hours when there is a change in the resident’s condition, and the LVN job description required completion of all required documentation and assistance in developing and updating plans of care.

The deficiency further includes failure to initiate or revise a care plan following a COC for the resident with diarrhea. Review of the resident’s undated care plan report showed no evidence that a care plan was initiated or updated to address the diarrhea COC documented on the SBAR form. In interviews, the treatment nurse stated that every COC required a care plan to be initiated and/or updated and that care plans guided staff on how to care for residents, what to expect, and what to monitor. The DON also stated that a COC was required to be care planned so there would be a plan of care in place to know how to treat the COC, and confirmed that the resident’s care plan was not initiated or revised following the documented COC.

Additionally, the deficiency includes failure to complete neurological checks according to facility policy following an unwitnessed fall for the resident with multiple fractures. The facility’s Neurological Flow Sheet and Fall Management Program policy required vital signs and neuro checks every 15 minutes for one hour, every 30 minutes for one hour (or two hours per the fall policy), every one hour for four hours, and then every four hours for the remainder of a 72‑hour period after an unwitnessed fall, unless discontinued by a physician. Review of the resident’s neurological checklists showed that post‑fall neuro checks were documented only at four time points over approximately 18 hours following the fall and hospital transfer/return, rather than at the frequencies specified in the neurological flow sheet and fall management policy. The DON stated that for an unwitnessed fall, neuro checks were expected to be ongoing for 72 hours after the fall, to begin immediately post‑fall and continue when the resident returned from the hospital, and confirmed that the assessments were not completed to her expectations and not in accordance with the timing flow chart.