Health inspection·August 19, 2021

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interviews the facility failed to ensure that medications were delivered in the manner prescribed for one resident (#21) of seven sampled residents. This resulted in medications being administered as crushed without an order or approval from the prescribing physician. The five errors observed during medication administration observations of 25 medications, represented an error rate of 20%. Residents Affected - Few Findings included: A review of the admission Record for Resident #21 revealed an admission date of 6/20/2020 and an initial admission date of 05/26/2017 with the primary diagnosis of cerebrovascular disease. Other diagnoses included Downs Syndrome, obesity, atherosclerotic heart disease, gastro-esophageal reflux disease (GERD) without esophagitis, schizophrenia, and anxiety disorder. A review of the active August 2021 physician orders for Resident #21 did not reveal an order stating, May change medication form as warrants (solid, liquid, crushed). Further review of the physician orders for Resident #21 did reveal orders for the following medications to be administered at 9:00 a.m.: - Quetiapine Fumarate Tablet 25 mg (milligrams) Give 0.5 tablet by mouth two times a day for schizoaffective disorder. - Escitalopram Oxalate tablet 10 mg Give one tablet by mouth one time a day for depression, - Acetaminophen 325 mg tablet Give two tablets by mouth every six hours as needed for pain management, - BusPIRone Hydrochloride (HCL)Tablet 5 mg Give one tablet by mouth three times a day for anxiety, - Divalproex Sodium capsule Delayed Release Sprinkle 125 mg Give one capsule by mouth three times a day for seizures, - Pantoprazole Sodium tablet delayed release 40 mg Give one tablet in the morning for GERD. On 8/18/2021 at 8:50 a.m. a medication administration observation with Staff A, Licensed Practical Nurse (LPN) revealed that Staff A, LPN crushed medications which included: Escitalopram Oxalate 10 mg tablet, Acetaminophen two tablets 325 mg tablets, Docusate sodium tablet 100 mg, Buspirone 5 mg tablet, and Quetiapine Fumarate 25 mg, half a tablet for Resident #21. Staff A, LPN stated that there was an order for the medications to be crushed and that order is one of the batch orders that are Page 1 of 2 105283 105283 08/19/2021 Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805

F 0759 completed for all residents on admission. Level of Harm - Minimal harm or potential for actual harm On 08/18/2021 at 10:05 a.m. an interview with Staff A, LPN was conducted. Staff A, LPN reviewed Resident #21's order sheet, and confirmed there was no physician order to crush the medications. Residents Affected - Few On 08/18/2021 at 10:22 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated that they completed a review of Resident #21's orders (physician) which revealed that the order to crush medications was not there, and she stated that the resident needs her medications crushed. Resident #21 had been sent to the hospital on 2/15/2021 and the prior order was discontinued. The order was supposed to be included in the batch orders on readmission, but it was not there. On 08/19/2021 at 1:30 p.m. a telephone interview was attempted with the facility's consultant pharmacist regarding the medication administration observation, and a message was left requesting a return call. At the time of exit from the facility no return call had been received. A review of the facility policy titled, Medication Administration General Guidelines, updated September 2018, revealed in Section 5: If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from the provider. a. The need for crushing medications is indicated on the resident's orders and the Medication Administration Record (MAR) so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during Medication Regime Reviews. 105283 Page 2 of 2