145555
10/10/2024
Evercare at Edwardsville
401 St Mary Drive Edwardsville, IL 62025
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 and record review, the facility failed to administer ordered medications to 1 of 5 residents (R2) reviewed for pharmacy services in the sample of 9.
Findings include: R2's Face sheet documents an admission date of 1/11/2024 with diagnoses of Metabolic encephalopathy, Alzheimer's, Interstitial Cystitis (chronic) with Hematuria, Dysphagia. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired. R2 is dependent on staff for activities of daily living (ADL's) and requires substantial assist for mobility and transfers. R2's Care Plan dated 10/2/2024 documents Problem: I have potential for pain/discomfort related to diagnosis of pain, Gastroesophageal Reflux Disease, GERD, Interstitial cystitis (chronic) with hematuria and constipation. Interventions include: Record/report to Nurse any signs/symptoms of non-verbal pain: Changes in breathing, vocalizations, mood/behavior changes, eyes, face, body. Observe the effectiveness of pain interventions every shift. Review for compliance alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R2's order sheet dated 7/25/2024 documents oxycodone - Schedule II. Tablet; 5 mg (milligrams); amt: (amount) 1 tablet; oral. Four Times A Day to be administered at 5:00 AM - 06:00 AM, 11:00 AM - 12:00 PM, 05:00 PM - 06:00 PM, 11:00 PM - 12:00 AM. R2's September 2024 Medication Administrator Record (MAR) document for R2's oxycodone 9/17/2024 5:00 AM - 6:00 AM Not Administered: Drug/Item Unavailable. 9/17/2024 11:00 AM - 12:00 PM Not Administered: Drug/Item Unavailable Comment: waiting on script. 9/17/2024 5:00 PM - 6:00 PM Not Administered: Drug/Item Unavailable. 9/17/2024 11:00 PM - 12:00 AM Not Administered: Drug/Item Unavailable. 9/18/2024 5:00 AM - 6:00 AM Not Administered: Drug/Item Unavailable. 9/18/2024 11:00 AM 12:00 PM Not Administered: Drug/Item Unavailable. 9/18/2024 11:00 PM - 12:00 AM Not Administered: Drug/Item Unavailable. 9/19/2024 5:00 AM - 6:00 AM Not Administered: Drug/Item Unavailable. 9/19/2024 11:00 AM - 12:00 PM Not Administered: Drug/Item Unavailable. 9/19/2024 11:00 PM - 12:00 AM Not Administered: Drug/Item Unavailable. 9/20/2024 5:00 AM - 6:00 AM Not Administered: Drug/Item Unavailable. 9/20/2024 11:00 AM - 12:00 PM Not Administered: Drug/Item Unavailable. R2's progress notes dated 9/19/2024 at 12:13 PM Call placed to Hospice letting them know that we
Page 1 of 2
145555
145555
10/10/2024
Evercare at Edwardsville
401 St Mary Drive Edwardsville, IL 62025
F 0755
need R2's pain medicine sent out as soon as possible.
Level of Harm - Minimal harm or potential for actual harm
On 10/9/2024 at 12:00PM V3, Assistant Director of Nursing (ADON), stated I am going to be honest with you. We have been having trouble with the hospice company (R2) is enrolled in. It looks like on 9/19/2024 we ran out of oxycodone for (R2), and hospice did not refill it.
Residents Affected - Few On 10/9/2024 at 9:30AM V11, (R2's family), stated Supposedly they were out of hydrocodone, and she was switched to oxycodone. We have trouble getting them to give her meds in the evening. I don't know what they give her now. The meds are just in pudding. On 10/10/2024 at 11:07AM V2, Director of Nursing (DON), stated V20, Registered Nurse (RN), called hospice several times about R2 needing a script for oxycodone. V20 (RN), did not chart that she had been calling so I knew nothing about it. On 10/9/2024 at 5:00PM V16 (RN) stated (R2's) oxycodone is not in the drawer. I will have to talk to (V2). We will have to call pharmacy. We cannot get in the E (Emergency) kit without a prescription. On 10/9/24, At 5:10PM V16 (RN) stated V2 already called for a script to get into the E kit. I have to wait to get approval to get the oxycodone out of the E kit. At 5:30PM V16 (RN) was approved to get an oxycodone out of E kit and administered oxycodone 5mg to R2. V16 (RN) stated R2's oxycodone will arrive tonight with pharmacy. Facility medication policy with a revision date of 4/2019 states Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frames.
145555
Page 2 of 2
