Health inspection·September 18, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to maintain a system of records to accurately account for all controlled medications in one of three medication carts inspected for six (Resident #2, #5, #6, #7, #8, and #9) of 15 sampled residents. Findings included: An inspection of a medication cart was conducted on 9/18/2023 at 1:00 PM on the Central Wing of the facility with Staff A, Registered Nurse (RN). Staff A was observed at the unit nurse's station with the medication cart's controlled medication log. Staff A stated she was in the process of signing out the controlled medications she administered to residents during the morning medication pass. Staff A stated she would normally sign the controlled medications out at the point of the medication being administered to the resident, but she was having trouble keeping up with her assignment and stated it was hard to stop and go during the medication pass. Staff A addressed several of the resident's controlled medication count sheets would be incorrect as a result of her not signing them out at the time they were administered. The following was revealed during the inspection of the medication cart: - 28 prefilled syringes of Ativan/Benadryl/Haldol (ABH) 0.5 milligrams (mg)/12.5 mg/1 mg cream prescribed to Resident #6. The medication monitoring/control record documented 29 doses remaining. Staff A stated Resident #6 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 11 tablets of Ativan 0.5 mg prescribed to Resident #2. The medication monitoring/control record documented 12 doses remaining. Staff A stated Resident #2 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 10 tablets of Clonazepam 0.5 mg prescribed to Resident #7. The medication monitoring/control record documented 11 doses remaining. Staff A stated Resident #7 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 6 tablets of morphine sulfate 15 mg prescribed to Resident #8. The medication monitoring/control record documented 7 doses remaining. Staff A stated Resident #8 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. Page 1 of 3 105248 105248 09/18/2023 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - A blister pack containing 9 tablets of Oxycodone/acetaminophen 5 mg/325 mg prescribed to Resident #8. The medication monitoring/control record documented 10 doses remaining. Staff A stated Resident #8 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 16 tablets of Oxycodone/acetaminophen 10 mg/325 mg prescribed to Resident #5. The medication monitoring/control record documented 18 doses remaining. Staff A stated Resident #5 was administered two doses of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 13 tablets of morphine sulfate 15 mg prescribed to Resident #9. The medication monitoring/control record documented 14 doses remaining. Staff A stated Resident #9 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 13 tablets of Oxycodone/acetaminophen 7.5 mg/325 mg prescribed to Resident #9. The medication monitoring/control record documented 14 doses remaining. Staff A stated Resident #9 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 4 tablets of Clonazepam 0.5 mg prescribed to Resident #9. The medication monitoring/control record documented 5 doses remaining. Staff A stated Resident #9 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. An interview was conducted on 9/18/2023 at 2:56 PM with the facility's Director of Nursing (DON). The DON stated he would expect nursing staff to complete documentation on the medication monitoring/control record when administering controlled medication as well as in the electronic medical record at the time the medication was administered. The DON stated he would not expect nursing staff to wait until the completion of their medication pass to document on the medication monitoring/control record because it was not best practice and would assume the medication was not administered if it was not documented on either the medication administration record of the medication monitoring/control record. A review of the facility policy titled Control Substance Administration and Accountability, implemented 10/24/2022, revealed under the section titled Policy it is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. The policy also revealed the following under the section titled Policy Explanation and Compliance Guidelines: F. All controlled substances are accounted for in one of the following ways: I. All controlled substances obtained from an automated dispensing system are accessed through the Remove function on the menu. II. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. 105248 Page 2 of 3 105248 09/18/2023 Oak Manor Healthcare & Rehabilitation Center 3500 Oak Manor Lane Largo, FL 33774

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some III. All specifically compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy. G. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR). H. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. Photographic evidence obtained. 105248 Page 3 of 3