Health inspection·October 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to follow its change in condition policy by not reporting the psychotropic medication adverse effect (drowsiness) to the provider. This applies to 1 of 6 residents reviewed (R1) for psychotropic medications/overdose/adverse effects in a sample of 6. The findings include: R1 was an [AGE] year-old female admitted on [DATE] with severe cognitive impairment per the Minimum Data Set (MDS) dated [DATE]. Record review on Physician Order sheet (POS) and Medication Administration Record (MAR) for 09/2023 document R1 was receiving Lasix 20 milligram (mg) daily, Mirtazapine 7.5 mg at bedtime, Sertraline 100 mg daily at 0900, Depakote 125 mg two times per day (0600 and 1800), Risperidone 2 mg two times per day (0800 and 2000, started on 5/18/23 and discontinued on 9/26/23), and Vistaril 25 mg two times per day (0900 and 1700). A review of the nursing Progress note dated 9/26/23, documented R1 was noted with a decline in condition, having episodes of lethargy. The documentation indicates the facility notified the Psychiatric Nurse Practitioner (Psych NP/V13), and the NP decreased the dose of the mood stabilizer and antipsychotic and ordered to continue to monitor the resident. Record review on POS documented the order for Risperidone was decreased on 9/26/23 from 2 mg to 1 mg twice daily. No other changes to R1's anti-psych medications. Record review on POS and MAR for 10/2023 document R1 was receiving Lasix 20 milligram (mg) daily, Mirtazapine 7.5 mg at bedtime (2100), Sertraline 100 mg daily at 0900, Depakote 125 mg two times per day (0600 and 1800), Risperidone 1 mg two times per day (0800 and 2000, started on 9/26/23 and discontinued on 10/07/23), and Vistaril 25 mg two times per day (0900 and 1700). A review of the nursing progress note dated 10/01/23 documents the facility held a Risperidone dose today due to sleepiness. Record review on MAR for 10/2023 document R1 was given Risperidone dose at 0800 and 2000 on 10/01/23. Record review on nursing progress note dated 10/02/23 and MAR for 10/2023 document R1 was drowsy, and the facility administered Risperidone dose along with other anti-depressants and mood stabilizers. Page 1 of 2 145333 145333 10/26/2023 West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/25/23 at 12:20 PM, V13 (Psychiatric Nurse Practitioner / NP) stated, The facility should monitor for adverse effects of psychotropic medications and report to the provider. They reported to me on 9/26/23, and I decreased the Risperidone dose from 2 mg to 1 mg. If R1 was still drowsy, the staff should have reported to me or the primary care physician. Record review on nursing progress note and POS indicates the facility didn't notify the primary care physician/NP about R1's adverse effect (drowsiness) after 9/26/23, while R1 remains drowsy with multiple psychotropic medication regimens. On 10/25/23 at 12:45 PM, V14 (Wound Care Nurse Practitioner) stated, A drowsy/lethargic patient is more vulnerable to develop pressure ulcer due to their decreased mobility and poor nutritional intakes. On 10/25/23 at 1:20 PM, V15 (Psychotropic Nurse / RN) stated, The floor nurses are supposed to notify me or V13 regarding the change in condition/adverse effects of psychotropic medications. They should have notified the provider if the patient continues to have the same adverse effects. The facility presented a Change of Condition Guidelines (reviewed on 02/03/2016) document: The process for identification of change of condition includes gathering objective data and documenting assessment findings, resident/patient response, and physician and family notification. A review of the facility presented Psychotropic Drug Usage Policy (dated 11/17) documents: 1. Each resident receiving an antipsychotic medication for organic brain disorders (dementia) is observed for adverse reactions and side effects. 145333 Page 2 of 2