145470
05/12/2023
Heritage Health-Hoopeston
423 North Dixie Highway Hoopeston, IL 60942
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 interview and record review, the facility failed to notify a resident's (R38) primary care physician of repeated refusal to take prescribed medications. This failure affects one resident (R38) of 12 residents reviewed for medication in the sample list of 30.
Findings include: R38's Physician Order Sheet (POS) dated 5/11/23, documents Aspirin Tablet Delayed Release 81 milligram give one tablet by mouth in the morning, Calcium 600+D Tablet 600-400 milligram-unit (Calcium Carbonate -Vitamin D) give one tablet by mouth in the morning, Cholecalciferol Tablet 50 micrograms (2000 UT) give one tablet by mouth in the morning, Cranberry Tablet 450 milligrams give one tablet by mouth in the morning for prevention of urinary tract infection, Docusate Sodium Oral Tablet 100 milligrams give one tablet by mouth two times a day, Gemfibrozil Tablet 600 milligrams give one tablet by mouth two times a day, Losartan Potassium Tablet 100 milligrams give one tablet by mouth in the morning, Memantine HCI five milligrams one tablet by mouth two times a day related to Unspecified Dementia, Multivitamin Tablet give one tablet by mouth in the morning, Seroquel Oral Tablet 50 milligrams give 50 milligrams by mouth in the [NAME] related to Unspecified Dementia, Unspecified Severity, with Agitation, and Sertraline HCI Oral Tablet 100 milligrams give 150 milligrams by mouth in the morning related to Major Depressive Disorder, Recurrent. R38's Physician Order Sheet (POS) dated May 2023, documents R38's diagnoses as Major Depressive Disorder, Recurrent, Unspecified, Mood Disorder Due to Known Physiological Condition, Unspecified, Anxiety Disorder, Unspecified, and Unspecified Dementia, Unspecified Severity, with Agitation. R38's Care Plan dated 5/4/23, documents R38 uses antipsychotic medications related to behavior management- administer medications as ordered. This Care Plan also documents R38 uses an antidepressant related to Depression. R38's Medication Administration Record (MAR) dated May 2023, documents R38 refused morning medications on 5/7/23, 5/9/23, and 5/10/23. R38's Nursing Progress Notes dated 5/7/23 at 9:42 AM, documents resident (R38) refusing all medications this morning. There is no documentation of R38's physician being notified of R38 refusing R38's medication. R38's Nursing Progress Notes dated 5/9/23 at 9:49 AM, documents several attempts to see if resident (R38) would take her (R38) medications resident (R38) ended up not taking her (R38) meds (medications). There is no documentation at this same time of R38's physician being notified of R38 refusing R38's medications.
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145470
145470
05/12/2023
Heritage Health-Hoopeston
423 North Dixie Highway Hoopeston, IL 60942
F 0580
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
On 5/11/23 at 9:31 AM, V2 stated R38 has refused R38's medications three times in the last four days. On 5/11/23 at 3:11 PM, V2 stated R38 sometimes takes R38's medications and sometimes refuses and the nurse's should be calling R38's physician when R38 refuses R38's medications. The facility's Medication Policy dated 1/11/10, documents make sure the resident takes the medication and notify the physician of known medication error and follow orders received.
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145470
05/12/2023
Heritage Health-Hoopeston
423 North Dixie Highway Hoopeston, IL 60942
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a significant medication error by leaving eleven ordered morning medications at a resident's bedside. This failure affects one resident (R38) of 12 residents reviewed for medication administration observation in the sample list of 30.
Residents Affected - Few
Findings include: R38's Physician Order Sheet (POS) dated 5/11/23, documents Aspirin Tablet Delayed Release 81 milligram give one tablet by mouth in the morning, Calcium 600+D Tablet 600-400 milligram-unit (Calcium Carbonate -Vitamin D) give one tablet by mouth in the morning, Cholecalciferol Tablet 50 micrograms (2000 UT) give one tablet by mouth in the morning, Cranberry Tablet 450 milligrams give one tablet by mouth in the morning for prevention of urinary tract infection, Docusate Sodium Oral Tablet 100 milligrams give one tablet by mouth two times a day, Gemfibrozil Tablet 600 milligrams give one tablet by mouth two times a day, Losartan Potassium Tablet 100 milligrams give one tablet by mouth in the morning, Memantine HCI five milligrams one tablet by mouth two times a day related to Unspecified Dementia, Multivitamin Tablet give one tablet by mouth in the morning, Seroquel Oral Tablet 50 milligrams give 50 milligrams by mouth in the [NAME] related to Unspecified Dementia, Unspecified Severity, with Agitation, and Sertraline HCI Oral Tablet 100 milligrams give 150 milligrams by mouth in the morning related to Major Depressive Disorder, Recurrent. On 5/11/23 at 9:05 AM, V11 Licensed Practical Nurse (LPN) was taking R38's medication into R38's room and R38 held up a cup full of medications. At this same time R38 stated I did not take these medications. After looking at the medications, V11 stated to R38, these are all of your (R38's) morning medications. At this same time, R38 respond yes, they are but I (R38) did not take them. R38's Medication Administration Record (MAR) dated May 2023, documents R38 refused morning medications on 5/7/23, 5/9/23, and 5/10/23. On 5/11/23 at 9:31 AM, V2 Director of Nursing (DON) stated R38 has refused R38's medications three times in the past four days. V2 also stated medications should not be left in any resident's room and the nurses should be watching the residents take their medications. The facility's Medication Administration Policy dated 1/11/10, documents make sure the resident takes the medication.
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