Health inspection·January 22, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medication per physician parameters prior to hemodialysis which affected one resident (R2) in the total sample of 10 residents reviewed for improper nursing care. Residents Affected - Few Findings include: On 1/10/24 at 11:07 am, R2 stated that R2 goes to an external hemodialysis center for hemodialysis treatments on Tuesdays, Thursdays, and Saturday mornings at 4:45 am. R2 stated that R2 is transported to the external hemodialysis center approximately one hour before each session. R2 stated that R2 is to receive R2's Midodrine before leaving for the dialysis sessions for my blood pressure, and I have to tell the nurses about it. R2 stated that R2 has not received the Midodrine dose after reminding the nurse. R2's admission Record, documents, in part, diagnoses of , end stage renal disease, dependence on renal dialysis, encounter for surgical aftercare following surgery on the digestive system, personal history of COVID-19, gastroesophageal reflux disease, hemorrhage of anus and rectum, depression, type 2 diabetes mellitus, single subsegmental pulmonary embolism, acquired absence of left foot, chronic systolic heart failure, obstructive sleep apnea, Guillain-Barre syndrome, flaccid neuropathic bladder, sciatica, unsteadiness on feet, lack of coordination, hypertension, and fatigue. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R2 is cognitively intact. R2's Special Treatments, Procedures, and Programs section indicates that R2 receives dialysis. R2's Order Summary Report documents, in part, a physician medication order from 12/4/23 as follows: Check blood pressure prior to hemodialysis. If SBP < (less than) 100, please administer Midodrine. One time a day every Tuesday, Thursday and Saturday for hypotension, if SPB < 100. R2's hemodialysis order indicates Hemodialysis 3 times per week: Tues, Thurs, Saturday. Chair time 4:45 am. On 1/18/24 at 11:11 am, V39 (RN) stated that V39 works the night shift on R2's floor, and that R2 is alert, oriented times 3 to 4 (person, place, time, situation) and goes to hemodialysis every Tuesday, Thursday and Saturday morning. V39 stated that R2's pick up time for transportation to each hemodialysis session is 3:45 am. V39 stated, I usually take (R2's) vital signs 5 to 10 minutes prior to transportation picking up R2 for hemodialysis. V39 stated that at times, R2 would ask V39 for R2's Midodrine prior to hemodialysis, but that Midodrine is available PRN (whenever needed). When asked how does V39 document that V39 administered a resident's medication, V39 stated that V39 will click the medication in the electronic medication administration record (MAR) which charts that V39 Page 1 of 3 145336 145336 01/22/2024 Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered the medication on that date and time. When asked the purpose of Midodrine, V39 stated that it's to boost the blood pressure and that R2's blood pressure usually goes down after hemodialysis. V39 stated that R2's Midodrine is instructed to be given before hemodialysis. V39 stated that when V39 has checked R2's blood pressure reading before leaving for dialysis, It's usually too high. No need for the Midodrine. When asked if V39 administered R2's Midodrine prior to hemodialysis, No. I never administered it. Blood pressure was too high. In R2's Dialysis 1.2 - V7 form, dated 12/23/23, V39 (Registered Nurse, RN) documents, in part, that on 12/23/23 at 3:32 am, R2's lying blood pressure on the right arm is 93/54. R2's Medication Administration Record (MAR), dated 12/1/23 to 12/31/23, documents, in part, Midodrine HCl (Hydrochloride) Oral Tablet. 5 mg (milligrams). Give 1 tablet by mouth as needed for systolic blood pressure less than 100, prior to dialysis. No check mark with the nurse signature is documented on 12/23/23. R2's Care Plan, dated 12/13/23, documents, in part, a focus of (R2) has renal failure related to end stage renal disease with an intervention of give medications as ordered by physician. R2's Care Plan, dated 10/30/23, documents, in part, a focus of (R2) requires hemodialysis with an intervention of obtain vital signs and weight per protocol. Facility policy dated 7/28/23 and titled Medication Pass, documents, in part, Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Procedures: . PO (oral) meds: . e. After medication is administered to each resident, sign MAR that it was given. On 1/18/24 at 1:13 pm, V2 (Director of Nursing, DON) stated that nurses know when medications are due by checking the EMAR (electric medication administration record) for scheduled and PRN medications. V2 stated, Nurses sign the EMAR that it's (medication) administered. V2 stated that a check with the nurses initials will be documented on the EMAR on the date and time of the nurse administering the medication. V2 stated that if a nurse is unable to administer a medication, due to resident refusing or the resident is not available on the floor to be given at a later time, then the nurse will document the reason why not administered which makes an EMAR note. When asked the expectation of nurses documentation that medications are administered, V2 stated, They (nurses) should document. That's immediate. They have to document that it's administrated. V2 stated, Medications are physician orders. Parameters are part of the orders. When asked the expectation of nurses to follow physician orders, V2 stated that nurses are to check the order summary reports Every day. Each time they (nurses) are working. They have to check. V2 stated that nurses must follow the physician ordered medication parameters. V2 stated that nurses check the resident's vital signs prior to the resident leaving for hemodialysis session. Facility policy dated 7/28/23 and titled Hemodialysis Policy, documents, in part, Policy Statement: It is the policy of the facility to ensure that appropriate care for resident on hemodialysis is provided by facility staff. Facility job description dated 5/5/15 and titled Registered Nurse, documents, in part, Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse (R.N.) plays a critical role in providing superior customer service and nursing care to all Guests and guests. The R.N. provides supervision of staff and will safeguard the health, 145336 Page 2 of 3 145336 01/22/2024 Warren Barr Gold Coast 66 West Oak Street Chicago, IL 60610

F 0684 Level of Harm - Minimal harm or potential for actual harm safety and welfare of all Guests/guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: . 5. Administer medications within the scope of practice of the R.N. Licensure . 10. Ensure that Guest care plans are being followed. Residents Affected - Few 145336 Page 3 of 3