Health inspection·June 14, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to store all drugs in locked compartments for one (Resident #4) of four sampled residents. Specifically, an expired Albuterol inhaler, not ordered by the physician, was found on the resident's bedside tray table. Failure to ensure safe and secure storage of all resident medications, can result in resident access to medications that are not their own among other potential concerns. The findings include: On [DATE] at 11:30 a.m., Licensed Practical Nurse (LPN) A was observed checking Resident #4's blood glucose level. An Albuterol inhaler was observed on the resident's bedside tray table. It was not labeled and the nurse did not remove it from the resident's room. On [DATE] at 11:35 a.m., Resident #4 was asked if she used this inhaler. She stated, Yes, I use it if I get short of breath. She was asked if she let staff know when she used the inhaler. She stated, No, should I be telling them? The inhaler was noted to have an expiration date of [DATE]. She stated she last used the inhaler yesterday (6/13). When she was asked if she was aware that the inhaler had expired in [DATE], she replied, No, I can't read that small writing. (Photographic evidence obtained) On [DATE] at 11:40 a.m., LPN A was asked if she was aware that Resident #4 had an Albuterol inhaler in her room on her bedside table. She stated, I didn't notice it. She was asked if Resident #4 had an order for an Albuterol Inhaler. She stated, Let me check and then stated, No, not an Albuterol inhaler, but an Albuterol nebulizer. She was asked if medications should be left in residents' rooms. She replied, No, they should be locked in the med cart unless they have an order to keep them in their room. She was asked if this resident had an order to keep medications in her room. She stated no. She was asked if she had checked the expiration date on the inhaler. She stated no, and then checked and stated, Oh, this expired in January of 23. On [DATE] at 11:50 a.m., in an interview with Registered Nurse (RN) B, she was asked if residents were permitted to have inhalers in their rooms. She stated, If they have an order and a self-administration evaluation. She was asked if she was familiar with Resident #4. She stated yes. She was asked if this resident had an order to keep any medications in her room. She stated, I had a long discussion about her inhaler with her the other day. She was asking for a long-acting inhaler but her doctor didn't want to order that. She was asked if the resident had the Albuterol inhaler in her room when she spoke with her. She stated yes. She was asked if she left the inhaler in the room when they Page 1 of 2 105917 105917 06/14/2023 Aviata at Jacksonville 4101 Southpoint Drive East Jacksonville, FL 32216

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were done speaking. She replied yes. She was asked again if the resident had an order to keep medications in her room and self-administer. RN B stated, No, I don't see an order for that and I don't see that she is care planned for that. She was asked what the expiration date on the Albuterol inhaler was. She looked at the inhaler and stated [DATE]. A medical record review for Resident #4 revealed diagnoses including type 2 diabetes, COPD (Chronic Obstructive Pulmonary Disease), dyspnea, CKD (Chronic Kidney Disease), heart failure (unspecified), and anemia. The resident's medical record contained no physician's order for an Albuterol inhaler. The record review revealed an order written on [DATE] for the following: Albuterol Sulfate Inhalation Nebulizer Solution (2.5mg/3ml) 0.83%: 3 ml: inhale orally via nebulizer every 6 hours as needed for SOB (shortness of breath). A review of the eMAR (electronic medication administration record) revealed that this medication had not been signed out as having been administered since it was first ordered on [DATE]. A review of the facility's policy titled Self-Administration of Medication at Bedside (revised [DATE]) revealed: The resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medications and to keep accurate documentation of these actions. Procedure: The eMAR must identify that meds are self-administered and the medication nurse will need to follow-up with resident as to documentation and storage of medication during each med pass. If kept at bedside, the medication must be kept in a locked drawer. . 105917 Page 2 of 2