Health inspection·January 11, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to supervise a resident that ingested another resident's medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for supervision with medication. The findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/2023 at 1:13 AM. Soon after delivery, V19 left the medication on top of V20's (RN) medication cart which was inside a locked unit. V19 did not inform V20 of the delivery. Around 4:30 AM, V21 (CNA-Certified Nurse Assistant) saw R1 walking around the unit and holding a bingo card of medication (Chlorpromazine 25 mg (Milligrams), 30 tablets). The medication she was holding was for another resident. V21 noticed that 18 tablets were popped. V21 found 8 tablets on the floor. Ten tablets were not found. R1 was noted to have a whitish substance on her mouth. R1 was brought to her room and was assessed. R1's heart rate was 116 beats per minute. R1 became lethargic and she was sent to a local hospital where admitting diagnoses were drug overdose, tachycardia and altered mental status. R1's admission Records showed her original admit date was on 11/10/2022. R1 was discharged to a local hospital on [DATE] and was readmitted on [DATE]. Diagnoses include accidental poisoning by unspecified drugs, medications and biological substances and dementia. R1's MDS (Minimum Data Sheet) dated 11/10/2023 documented R1's cognition as moderately impaired and needed supervision or touching assistance with ambulation. R1's MDS dated [DATE] documented R1's cognition as severely impaired and needed supervision or touching assistance with ambulation. On 1/9/2024 at 10:12 AM, V7 (RN) said the incident could have been avoided if the medications were secured and if staff were aware that R1 was walking around the unit at that time. On 1/9/2024 at 12:19 PM, V17 (NP-Nurse Practitioner) said R1 accidentally ingested unknown amounts of Chlorpromazine 25 mg and became lethargic that is why she was sent to a local hospital for further evaluation. She said Chlorpromazine is very sedating and caused R1 to be lethargic. She said if medications were properly stored and if staff saw R1 walking around, the incident would not have happened. On 1/9/2024 at 12:30 PM, V4 (ADON) said R1 would not have accidentally ingested 10 tablets of Page 1 of 3 145329 145329 01/11/2024 Norridge Gardens 7001 West Cullom Norridge, IL 60634

F 0689 Chlorpromazine 25 mg if the medication was properly stored and if R1 was supervised while walking around the unit. Level of Harm - Actual harm Residents Affected - Few On 1/9/2024 at 1:21 PM, V18 (Psychiatric NP) said side effects of Chlorpromazine includes lethargy and dizziness, EPS (Extra Pyramidal Symptoms). She said Chlorpromazine causes tachycardia. She said R1 was sent to the hospital so she can be closely monitored after accidentally ingesting Chlorpromazine. On 1/11/2024 at 9:18 AM, V3 (DON-Director of Nursing) said R1 would not have accidentally ingested Chlorpromazine if she was being supervised while walking around the unit. R1's Hospital Records dated 12/18/2023 at 7:30 AM documented R1 came to ER (Emergency Room) due to altered mental status and drug overdose. Upon arrival to ER, R1 was very somnolent and arousable only to painful stimuli. Diagnosis was altered mental status and drug overdose. Facility's Policy titled Safety and Supervision of Residents revised in March 2020 stated the following: . Policy Statement: The facility strives to make the environment as free from accident hazards as possible. Resident safety supervision and assistance to prevent accident is a priority. 7. Resident supervision is a core component of the system's approach to safety. 145329 Page 2 of 3 145329 01/11/2024 Norridge Gardens 7001 West Cullom Norridge, IL 60634

F 0761 Level of Harm - 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. Based on interview and record review, the facility failed to safeguard and properly store a medication that led to a confused resident ingesting that medication. This failure resulted in R1 being hospitalized for drug overdose, fast heartbeat, and altered mental status. This applies to one out of seven residents (R1) reviewed for medication storage. Findings include: On 1/9/2024 at 12:50 PM, V4 (ADON-Assistant Director of Nursing) said an incident occurred on 12/17/2023 between the hours of 4:30 AM to 5:00 AM. He said V19 (RN-Registered Nurse) received a delivery from pharmacy on 12/17/23 at 1:13 AM. Soon after delivery, V19 left the medications on top of V20's (RN) medication cart which was inside a locked unit without informing V20 of the delivery. R1 was noted holding one bingo card of Chlorpromazine (Antipsychotic) 25 mg (milligrams) with 30 tablets. It was noted that 18 tablets were missing. R1 was noted to have a whitish substance on her mouth. R1 was brought to her room and was assessed. R1's heart rate was 116 beats per minute. R1 became lethargic and she was sent to a local hospital where admitting diagnoses were drug overdose, tachycardia and altered mental status. On 1/9/2024 at 10:12 AM, V7 (RN) said the incident could have been avoided if the medications were secured. On 1/9/2024 at 12:19 PM, V17 (NP-Nurse Practitioner) said R1 would not have accidentally ingested unknown amounts of Chlorpromazine 25 mg and became lethargic if medications were properly stored. On 1/9/2024 at 12:30 PM, V4 (ADON) said R1 would not have accidentally ingested 10 tablets of Chlorpromazine 25 mg if the medication was properly stored. On 1/9/2024 at 12:50 PM, V3 (DON-Director of Nursing) said the incident would have been avoided if the medications were secured in the medication cart or the medication room as she expects the nurses to do. She said she expects the nurses to store all medications in the medication cart or the medication room for safety and security reasons and so nobody, including residents, staff, or visitors, could get access to the medications. Facility's Storage Medication Policy revised on March 2020 states the following: . Policy Statement: The facility shall store all drugs and biologicals safely, securely, and orderly.Locked Compartments .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 145329 Page 3 of 3