Health inspection·April 1, 2024

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 interview, observation, and record review, the facility failed to provide the physician ordered pain medication for 1 of 3 residents (R3) reviewed for pharmacy services in the sample of 3. Findings include: R3's admission Record Form, undated, documented R3 was admitted on [DATE] with diagnosis of Infection and Inflammatory reaction due to internal Left knee prosthesis. R3's Minimum Date Set, dated 1/30/24, documents R3 is cognitively intact. R3's Physician Order, start date of 1/23/24, documents, Oxycodone-Acetaminophen Oral Tablet 5-325 MG (Oxycodone w (with)/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for chronic pain. R3's Nurse's Note, dated 3/25/2024 08:58, documents, Nurses Note Late Entry: Narrative: Placed an order to send oxycodone stat (immediately). R3's Nurses Note, dated 3/26/2024 09:00, documents, Nurses Note Narrative: per pharmacy oxycodone will be out in am delivery resident's pain assessed and an alternative prn (as needed) for pain offered. R3's Medication Administration Record, dated March 2024, documents that R3 did not receive any Oxycodone - Acetaminophen tablets from 3/23/24 - 3/25/24. R3 did receive a dose of Oxycodone Acetaminophen on 3/26/24 at 5:18 PM. On 4/1/24 at 8:50 AM, R3 stated he has an antibiotic spacer in his left knee and the doctors want to cut his leg off, but he does not want to lose his leg. He stated there is a wound on the left leg that hurts. R3 stated the right leg is broken and has been for 2 years. He pulled the covers back and the right thigh was extremely swollen. R3 said he must get up with a (full mechanical lift). R3 stated, Last Friday I ran out of my pain medication. I did not get a dose until Tuesday morning around 9:30 AM. They said that they didn't order it and when they did it never came in. I usually run out at the end of the month. The 0-10 pain scale was explained to R3 and that 10 is the worst pain that he has ever felt. R3 stated, My pain was a 30 for those 4 days. It hurt so bad I couldn't move. On 4/1/24 at 1:17 PM, V3, Licensed Practical Nurse (LPN), stated she did take care of R3 over the weekend of 4/23/24 and 4/24/24. V3 stated, He was out of Oxycodone, and I sent his prescription to Page 1 of 2 145160 145160 04/01/2024 Arcadia Care on the Hill 555 West Carpenter Springfield, IL 62702

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the pharmacy to get filled. I offered R3 Tylenol, but he did not want that. He said that he was in pain, but he was acting his normal self-telling jokes and stuff. I did not see any obvious signs of pain. On 4/1/24 at 1:25 PM, V5, LPN, stated, I came in Monday morning and the night nurse (V7) told me R3 was out of his pain medication because he needed a new prescription. She (V7) had put the request in for the Nurse Practitioner and it should be taken care of today. I went in and told (R3) all of this. He said he was in pain, but he was acting like he does all the time. I did not see physical signs of pain. On 4/1/24 at 10:45 PM, V2, Director of Nurses, stated, (R4's) insurance advocate came and told me on Monday 3/25/24 that (R4) was out of pain medication. I told her I did not know that so I would look into it. I went and spoke to his nurse (V5), and I told her to give him some Tylenol since he does have that. I went and ordered the medicine STAT (immediately) from pharmacy. On 4/1/24 at 1:10 PM, V2 stated the prescription that was sent to pharmacy on 3/23/24 ended up not having any more refills on it so R3 needed a new prescription written and sent to pharmacy. V2 stated, That is what the problem was. On the 25th the order was put in STAT, but our pharmacy has a cut off time that is why it didn't come until the 26th. (R3) was saying he was having pain, but he always says that. I see him multiple times a day. He sits right outside of my office, and he never complained to me about his pain. He was acting like his normal self. On 4/1/24 at 2:05 PM, V1 stated she has been looking for the pharmacy policy but it unable to locate it at this time. V1 stated if the nurses run out of a medication, they should put in for a refill and continue to contact pharmacy if it is not delivered timely. 145160 Page 2 of 2