Health inspection·December 18, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure there were no discrepancies between the narcotic records and the residents' medical records for three (Residents #3, #4, #5) of three residents who had physician's orders for and received narcotics to relieve their pain. Findings included: 1. Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction and Pressure Ulcers to her sacral region. A review of Physician Orders revealed an order for tramadol HCl 50 mg, one tablet by mouth every 6 hours as needed for pain, with a start date of 11/30/2023. On 12/18/2023 a short interview was conducted with the resident beginning at 10:15 a.m. The resident was observed sitting in her wheelchair with both legs bent at the knees and drawn up to her chest. She was leaning toward her left side. She was agreeable to an interview and while answering questions, it was noted that she was moaning and fidgeting in her chair. When asked if she was in pain, she agreed and said she wanted to ask her nurse for her pain pill. At that same time, the resident's aide walked into the room and she confirmed she had told the nurse the resident was ready for a pain pill. The surveyor left the room and spoke with the resident's nurse who confirmed she was aware the resident was asking for her pain pill. She reported the resident preferred to ask for the pain pill, and usually was very specific about the time that she wanted it. A review was conducted of the Medication Administration Sheets (the MAR) , the Nurse's notes, and the Controlled Drug Declining Inventory Sheet (the Narc Count Sheet) to ensure all entries matched and the administration of the tramadol was accounted for and documented. Several discrepancies were noted. On 12/07/2023 at 9:00 a.m. the Narc Count Sheet listed one tramadol was administered, but the administration was not documented on the MAR or in the Nurse's notes. On 12/08/2023 at 12:00 p.m. the Narc Count Sheet listed one tramadol was administered, but it was not documented on the MAR or in the Nurse's notes. On 12/18/2023 the Narc Count Sheet did not list a second dose as administered but the MAR and the Nurse's notes documented a dose was administered at 12:07 p.m 2. Resident # 4 was admitted to the facility on [DATE] after having sustained a fractured lower end of the right radius and a displaced fracture of the right ulna after a fall. A review of Physician Orders revealed an order at admission for Percocet Oral Tablet 5-325 mg, give one tablet by mouth every 6 hours as needed for acute pain. This order was in place until 12/11/2023 when the order Page 1 of 3 105393 105393 12/18/2023 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0755 Level of Harm - Minimal harm or potential for actual harm changed to oxycodone - acetaminophen oral tablet 7.5-325 mg , give one tablet by mouth every 6 hours as needed for pain. On 12/18/2023 at 10:10 a.m. the resident was observed sleeping in bed, in a sitting position with her back against the elevated head of the bed. Residents Affected - Few On 12/18/2023 at 10:25 a.m. the resident was observed in her bed, but awake. She welcomed the surveyor into her room and reported she was fine. She confirmed she enjoyed falling back to sleep after eating breakfast. She reported she had pain at times, but she did not have a prescription for narcotics. Her right arm was observed in a cast which was resting on the bed. A review was conducted of the MAR with comparison to the Nurse's notes and the Narc Count Sheet and showed the following: On 12/07/2023, the Narc Count Sheet listed one pill was administered at 2:30 a.m. which was not documented in the MAR or in the Nurse's notes. On 12/10/2023, the Narc Count Sheet listed one pill was administered at 11:50 a.m. but it was not documented in the MAR or in the Nurse's notes. On 12/11/2023, the Narc Count Sheet listed one pill was administered at 2:20 p.m. but it was not documented in the MAR or in the Nurse's notes. On 12/15/2023, the Narc Count Sheet listed one pill was administered at 5:30 a.m. and a second pill was administered at 12:15 p.m., but neither were documented in the MAR or in the Nurse's notes. On 12/18/2023, the Narc Count Sheet did not list any pills as administered, but the MAR and the Nurse's notes contained documentation at 10:54 a.m. for the administration of one pill. 3. Resident #5 was admitted to the facility on [DATE] with diagnoses that included Hypertensive Chronic Kidney Disease, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Spinal Stenosis. A review of the Physician's orders revealed an order for Hydrocodone -Acetaminophen 5-325 mg, give one tablet by mouth every 6 hours as needed for pain. A review was conducted of the MAR with comparison to the Nurse's notes and the Narc Count Sheet showed the following: On 12/06/2023 the Narc Count Sheet listed one pill as given at 10:00 a.m., but it was not documented in the MAR or in the Nurse's notes. On 12/07/23 the Narc Count Sheet listed one pill as given at 1620 (4:20 p.m.). The MAR and the Nurse's notes documented the pill was given at 2019 (8:19 p.m). On 12/18/2023 beginning at 12:20 p.m. an interview was conducted with the Director of Nurses (DON). When asked about concerns with missing medication or diversion of narcotics, she reported that she had investigated one occurrence a few months prior, but had not been made aware of a continuing problem. She reported all nurses had received education on medication administration and how to document 105393 Page 2 of 3 105393 12/18/2023 Bear Creek Nursing Center 8041 State Rd 52 Hudson, FL 34667

F 0755 that administration. She denied having been told of a continued problem, especially with agency nurses. Level of Harm - Minimal harm or potential for actual harm The concerns identified with Resident #3 , #4, and #5 were discussed with the discrepancies observed in the documentation reviewed. The DON confirmed the discrepancies were a problem and there would have to be more education with the nurses. Residents Affected - Few On 12/18/2023 beginning at 2:40 p.m., an interview was conducted with the Risk Manager/Unit Manager (RM/UM). The RM/UM confirmed there had been education conducted with the nurses on receiving narcotics from the pharmacy and documentation that had to be made when administering narcotics. She reported she had not been told by nurses the narcotic counts were incorrect. She confirmed she had not been made aware of agency nurses who were not documenting administering narcotics to residents. A review was conducted of the facility's policy entitled Administering Medications. The Policy heading read: Medications are administered in a safe and timely manner and as prescribed. Point #4 under Policy Interpretation and Implementation read: Medications are administered in accordance with prescriber orders, including any required time frame. Point # 6 read: Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. Point #22 read: The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 105393 Page 3 of 3