Health inspection·October 19, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a resident was properly identified prior to medication administration to prevent medication errors as per facility policy. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for medication errors in a sample of 7. The findings include: MDS (Minimum Data Set), data 8/30/23, shows R1 was cognitively intact. R1's MAR (Medication Administration Sheet), dated 9/1/23 to 9/30/23, shows R1 had physician orders for the following medications during the month of 9/2023: Oyster Shell Calcium, Ergocalciferol, Flomax, Gabapentin, Glipizide, Levothyroxine, Loratadine, Melatonin, Metoprolol Extended Release, Pravastatin Sodium, Diclofenac gel, albuterol, docusate, guaifenesisn, and acetaminophen. On 10/18/23 at 12:47 PM, R1 was sitting in a wheelchair in a small dining room and was alert, oriented, communicative, and well groomed. R1 stated, I feel OK now! R1 stated on 9/26/23, R1 was approached by V3 (Registered Nurse) who stated she was going to provide R1 his due medications. R1 stated he usually received medications at that time but when V3 provided medications to R1, R1 did not recognize the medications he was given and told V3 that the medications were not his. R1 stated he took the same medications for years and knew his medications by sight. V3 told R1 that the medications were R1's medications, but never asked R1 his name, checked for any identification, or checked is identification bracelet. R1 stated V3 left R1, walked to her medication cart, and returned to R1 telling R1 that his physician changed his medications and that the medications she provided were his. R1 stated he swallowed the medications and V3 returned to her medication cart. R1 stated V3 then returned to R1 with a paper in her hand, looked at the paper, and stated the paper had a different name written on it. R1 stated he told V3 the name on the paper was not R1's name. R1 stated V3 walked away and R1 went to his room. R1 stated he started to feel strange, told a different staff member he did not feel well, and the facility staff placed him on the toilet and encouraged him to drink water. R1 stated after telling the staff twice he was feeling dizzy while sitting on the toilet, the staff transferred him to his wheelchair. R1 stated he told staff he wanted to go to the hospital but the staff did not send him at that time. R1 stated eventually paramedics came in and took him to the hospital. R1 stated he was very upset, very scared, and did not know what to think. R1 stated he was scared because he was allergic to sulfa drugs and was afraid for hours that he might die due to the medications given in error. R1 stated he felt safe in the hospital and then better when he returned to the facility. On 10/18/23 at 11:24 AM, V3 (Registered Nurse) stated the day she floated to work on R1's unit, there were four new residents on the unit. V3 stated R1 was not new and thought she recognized R1, but Page 1 of 3 145050 145050 10/19/2023 Dupage Care Center 400 N County Farm Rd Wheaton, IL 60187

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V3 had not worked with R1 for some time. V3 stated she retrieved medications from her medication cart after checking the computer. V3 stated when she pulled up a resident to retrieve his medications and she thought R1 was the resident for which she was gathering medications. V3 stated she later realized the medications were prescribed for R7. V3 stated she forgot to check R1's patient identification band, check the back of R1's chair for his name, or check the computer for R1 name or picture. V3 stated R1 did question if the medications were his and also questioned why V3 checked R1's blood sugar because staff had already checked it earlier. V3 stated she then gave R7's oral medications to R1, including Coreg, Valsartan, and Eliquis, which R1 swallowed. V3 stated she also gave R1 eye drop medications and R1 told V3 he was not supposed to be receiving eyedrops. V3 stated she returned to her computer and reviewed R1's medication. V3 stated she noticed she had not yet provided insulin as was ordered for R7, drew up the insulin, and returned to R1 to provide the insulin. V3 stated R1 told V3 he did not take insulin as one of his medications. V3 stated that was when she realized she gave the wrong medications to the wrong resident and informed her supervisor immediately. V3 stated R1's physician and emergency contact were informed of the error immediately. V3 stated R1's blood pressure was initially normal but later dropped at approximately 8:00 PM and R1's physician was notified. R1's physician sent R1 to the hospital and V3 was suspended from her position at the facility. On 10/18/23 at 10:15 AM, V7 (Pharmacist) stated a resident who was regularly takes Metoprolol and who is given one dose of both Coreg and Losartan by mistake can experience dizziness and lightheadedness due to low blood pressure and low pulse rate. V7 stated R1 was given Coreg and Metoprolol, two beta blockers, which can cause a significant decrease in a resident's blood pressure and heart rate. R1 was also given Losartan which could further lower his blood pressure in addition to the two beta blockers. V7 stated in a resident sensitive to the medications, the three could provoke a resident to have a high risk of falling and injury. V7 stated if a resident's blood pressure were low enough for a sustained period of time, organ failure may result, but that those results would not likely occur due to the one-time, low doses that were administered. V7 stated that one dose of Eliquis would not be concerning with R1's diagnosis. On 10/18/23 at 10:27 AM V2 (Director of Nursing) stated V3 floated as a nurse at the facility for many years. V2 stated as soon as V3 made the medication error, V3 notified her supervisors. R1's physician was notified and gave orders to closely monitor R1. V2 stated R1's blood pressure began to drop within a few hours of close monitoring, and R1's physician was called again who ordered R1 to be given additional fluids. V2 stated the facility staff lowered R1's head of bead when R1 began to complain of dizziness and R1's blood pressure still dropped further. V2 stated R1's physician was called and ordered R1 to be sent to the hospital for closer monitoring. V2 stated R1 was admitted back to the facility within several hours and all facility nurses were provided re-training on medication administration. V2 stated it was her expectation that nurses utilize three identifiers, resident pictures, asking residents their names, and checking resident identification bands, prior to providing medications. On 10/18/23 at 1:06 PM, V8 (Physician) stated when he was told R1 mistakenly received another resident's medications including two beta blockers, V8 told the staff to monitor R1's pulse and blood pressure for changes. V8 stated the mistaken doses of Coreg and Losartan provided to R1 were not very high, but R1's pulse and his blood pressure was V8's main concern. V8 stated when R1's blood pressure dropped lower, V8 stated he considered providing intravenous fluids at the facility but instead decided to send R1 to the hospital for closer monitoring. V8 stated he was concerned R1's pulse and blood pressure could drop which could cause dizziness/fainting and R1 to fall if he were standing. V8 stated R1 was with staff and either sitting or in bed, so his risk of falling was mitigated by staff supervision. V8 stated there could be a 145050 Page 2 of 3 145050 10/19/2023 Dupage Care Center 400 N County Farm Rd Wheaton, IL 60187

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concern with death with higher/sustained doses of the additional medications given, but it would be very unusual with the one time, lose doses of the medications that were provided. V8 stated he never saw a resident die of a one time dose of the medications R1 was provided and death for R1 would have been very, very unlikely. Progress note, dated 9/26/23, shows R1 reported a nurse gave him the wrong medication. R1 was monitored for any adverse reactions and side effects. The progress note shows during the monitoring of R1's blood pressure after being given the wrong medications, R1's blood pressure dropped from 116/77 mmHg (millimeters of mercury) at 6:00 PM to 75/63 mmHg at 10:15 PM. The progress shows R1's physician was called and R1 was ordered to be sent to the hospital via 911. Hospital records, dated 9/26/23, show R1 was reported to have systolic blood pressures in the 80's mmHg and R1 received the wrong resident's medications. The physical exam shows R1's blood pressure was initially 88/50 mmHg and R1's heart rate was normal and regular at the hospital. The records show R1 was provided fluids during observation at the hospital, was asymptomatic, and his blood pressure improved to 120/66 mmHg as of 9/27/22 at 6:09 AM. Physician Note, dated 9/27/23, shows R1 returned from the emergency room after being given the wrong medications, his blood pressure becoming low, and becoming tired. MAR, dated 9/2023, shows R7 had physician medication orders which included Coreg, Losartan, Eliquis, Artificial tears, and insulin Aspart solution at 5:00 PM on 9/26/23. Medication Administration Policy, revised 10/2023, shows the purpose of the policy was to assure that all medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The policy shows, Medications prescribed for one resident cannot be administered to another resident Identify the resident in the following 3 ways: a. Ask the resident to state his/her name. b. Identify resident by reading wristband and checking the picture on the MAR (Medication Administration Record.) 145050 Page 3 of 3