Ocean Park Healthcare

During an interview on 4/22/2025 at 12 PM with LVN2 stated, during new admissions, emergency medical technicians bring a transfer packet with residents.

The transfer packets usually include medication list, history and physical, lab results, and code status.

During admissions, medications are notified to attending physicians right away for review and approvals.

Medication reconciliations is done by admitting nurse.

Registered Nurse supervisors or Director of Nursing (DON) conduct medication reconciliations review after each admission.

Transfer records are uploaded in the care system by medical records for licensed staff to carry out orders.

During a telephone interview on 4/22/2025 at 12:27 PM with Pharmacy supervisor (PharmD2) stated, the process for medication to be dispensed, the facility obtains medication order lists from transferring hospital, facility staff gets approval by attending physician, then staff sends the medication orders to pharmacy.

Pharmacy reviews order and dispenses medications within same day of admission, usually between four to six hours from admission time.

PharmD2 confirmed Resident 1 was admitted to the facility on [DATE].

PharmD2 stated, the pharmacy did not receive an order for apixaban/Eliquis.

Pharmacy cannot dispense without orders.

This was the response from the pharmacist. I can rephrase it - Pharmacy does not dispense medications without MD orders.

During a concurrent interview and record review on 4/22/2025 at 12:53 AM with Registered Nurse supervisor (RN), Resident 1 ' s GACH Physician Transfer Order dated 2/14/2025 was reviewed. RN stated the admitting nurse is the responsible person to review and reconcile medications. RN supervisor or DON will review the medication reconciliation the same day or next day to ensure interfacility transfer medication list is accurately reconciled. RN stated, Resident 1 was admitted to the facility on a Friday afternoon. RN started basic assessment and endorsed the admission process to the evening shift charge nurse. RN did not review the medication (the RN did not get a chance to complete revision of meds, he endorsed to the charge nurse), did not complete reconciliation because the resident was admitted after the RN ' s end of shift. RN not aware if Resident 1 ' s medication was reviewed by another RN supervisor or DON.

The resident was transferred to a sister facility within two days. (RN reviewed and acknowledged Physician Transfer Order indicated apixaban/Eliquis 5mg tablet was part of the list of medications. Resident 1 ' s MAR indicated, apixaban/Eliquis is not included in the medication orders. RN agreed apixaban/Eliquis was not ordered and administered to Resident 1. RN stated, It is a deficiency and harm risk for the resident.

During a telephone interview with on 4/22/2025at 1:25 PM with attending physician (MD) stated, he is the provider for the facility. Resident 1 was randomly assigned to him during admission.

Facility staff had called him and reviewed the medication and approved the existing mediations. MD stated, Resident 1 was on anticoagulant (blood thinner), I do know he was supposed to be on anticoagulant. MD had provided telephone order to facility staff for approval of existing transfer medications from GACH.

555786

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555786 B.

Wing 04/22/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405