Health inspection·June 13, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and a review of the facility's policy and procedure, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to administer scheduled medications within the required timeframes per the ordered times and the facility's policy, allowing for administration one hour before to one hour after the scheduled time for two (Residents #4 and #1) of eight sampled residents. Failure to administer medications timely could result in changes to therapeutic drug levels, ineffective pain management, development of antibiotic resistance, unregulated blood pressures, unregulated blood sugar levels and more. Residents Affected - Few The findings include: On 6/13/23 at 10:31 a.m., Licensed Practical Nurse (LPN) A was observed during morning medication administration. She was preparing medication for Resident #4. An observation of the resident's electronic Medication Administration Record (MAR), revealed that the text color was red. When LPN A was asked what the red type indicated, she replied, The MAR is set up to show red if the medication is an hour past the administration time. When she was asked if there was a process for obtaining help when medication administration was running late, she replied that she was not sure. On 6/13/23 at 10:47 AM, an interview was conducted with LPN B, who was in the process of dispensing medications for Resident #1. The electronic MAR text was red. When she was asked what the significance of the red text was, she replied, It means we are outside the one-hour window. With thirty residents and not knowing them, it's impossible to get all the meds out on time. When she was asked if anyone was available to help ensure the medications were administered timely, she replied that she did not know. She stated she did a quick review of the residents' medications to determine which medications/residents were a priority. She administered those medications and then finished medication administration for the rest of her assigned residents. On 6/13/23 at 12:25 PM, an interview was conducted with Registered Nurse (RN) C, former Director of Nursing (DON) for this facility, now at a sister facility, but brought in to assist with this survey. RN C confirmed that the medication administration window was one hour before to one hour after the scheduled administration time. If the medication was not administered within this window of time, the resident's physician was to be notified to change the dispensing time if not contraindicated. When he was asked if there was a protocol for nurses to ask for help with medication administration when they were falling behind, he replied that they should be letting someone know so we can try to find them help. When he was asked how often medications were not given at the scheduled time, he replied that he was not sure. On 6/13/23 at 12:50 PM, an interview was conducted with the Regional Nurse Consultant (RNC). When Page 1 of 2 105589 105589 06/13/2023 Coquina Center 170 N Center Street Ormond Beach, FL 32174

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was ssked if agency staff were oriented about who or how to ask for assistance with medication administration, she replied, They should be asking for help. I'm more likely to use an agency nurse who asks for help than one who does not and gets behind. When she was asked if she was aware of how often medications were administered late, she replied no. A review of the Medication Administration Audit Report for Residents #1 and #3 from June 3-13, 2023, revealed that Resident #1 received his medications beyond the one-hour past scheduled administration time for 106 of 239 opportunities (44% of the time during that period). Resident #3 received his medications beyond the one-hour past scheduled administration time for 23 of 136 opportunities (17% of the time during that period). A review of the facility's current Performance Improvement Projects (PIPs) revealed that the facility had not identified late medication administration issues. A review of the facility's policy for Administering Medications (revised April 2020) revealed on page. 1, Item #4 - Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. Item #6 -Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). . 105589 Page 2 of 2