Health inspection·February 10, 2024

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 interview, and record review, the facility failed to administer her IV (Intravenous) antibiotic as ordered by the physician. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for IV antibiotic use in the sample of 3. The findings included: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the left breast, chronic obstructive pulmonary disease, conversion disorder with seizures, acute respiratory failure with hypoxia and hypercapnia, type 2 diabetes, repeated falls, and ESBL (Extended Spectrum Beta Lactamase) in the blood and urine. R1 tested positive for Covid-19 on February 8, 2024. R1's MDS (Minimum Data Set) dated January 26, 2024, showed that R1 had moderately impaired cognition. R1's POS (Physician Order Set) showed Ertapenem 1 gram once a day (7:00 AM - 11:00 AM) for ESBL (Extended Spectrum Beta Lactamase). R1's progress notes were reviewed and showed the chest wall medication port needle had come out of R1's medication port on January 30, 2024. The facility did not have the needle needed to access her port and had to order more needles from the pharmacy. R1's MAR (Medication Administration Record) showed R1 missed doses on January 30, 2024 with no reason identified. R1 missed her dose on January 31, 2024, not administered waiting for needle. February 1, 2024, not administered waiting for access needle from pharmacy.and February 2, 2024, not administered needle not available. On February 9, 2024, at 12:55 PM, R1 was in contact isolation for ESBL in the urine and blood. R1 tested positive for Covid-19 on February 8, 2024, and was also placed in contact and droplet isolation. R1 said she feels very tired. R1 stated she was not given her IV antibiotics for 3 or 4 days until she went to the hospital, and they put a new needle into her port. R1 said since then she has been getting her IV antibiotics daily. On February 9, 2024, at 9:49 AM, (V4) (Hospital Social Worker) said that R1 had been in their hospital from [DATE], until January 24, 2024, when she was transferred back to the nursing home on IV (Intravenous Antibiotics). R1 came to the ER (Emergency Room) on February 2, 2024, after a fall at the Page 1 of 3 145609 145609 02/10/2024 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nursing home. When R1's family member came to the ER he said that her port access had been, accidentally dislodged and R1 had not received her IV (Intravenous) antibiotic for 2-3 days. V4 said the ER nurse called the facility to get more information. V6 (RN/Registered Nurse) at the facility said R1 had not received her antibiotic because they did not have the supplies to access her port. V6 told the ER nurse that the supplies were supposed to have been delivered on February 2, 2024, but they had not received them. V4 said the ER accessed the port and sent R1 back to the facility with the port accessed and ready to be used for medication administration. On February 9, 2024, at 1:18 PM, V5 (RN/Registered Nurse), said she was working the day shift on January 30, 2024, when she went into R1's room, and the needle to her chest wall medication port was out and lying on R1's chest. R1 said she thought she might have pulled the needle out while she was sleeping. V5 said she cleaned the chest wall medication port site and covered the area with dry dressing. V5 said she called the night shift nurse who had no idea the needle was out. V5 said there were no chest wall medications port needles in the facility, so V5 said she called the pharmacy to see if they could send her one. V5 said V8 (Pharmacist) told her these needles are a house stock item and would need an authorization form signed by the facility acknowledging they would pay for these needles before he could send them. V5 said V8 faxed over the form and V2 (DON/Director of Nursing) signed the form and faxed it back to the pharmacy the same day. V5 said she endorsed to the evening shift, that if the chest wall medication port needle came from pharmacy, R1 would still need her IV antibiotic which was ordered to be given once a day. V5 said they were unable to start a peripheral IV due to R1 having a history of breast cancer on the left breast, and there was a lot of swelling to her right hand/arm. V5 said she was off for a couple of days and when she came back there was still no needle. V5 said she called the pharmacy back and spoke to V8 who told her that they were out of the needles and had to order them, V8 also said he had spoken to someone from the facility the night before. V5 said this was when she called V7 (Physician) to make him aware she had missed 3-4 doses. V7 said to give her the antibiotic as soon as they get the needle. R1 ended up going out to the hospital on February 2, after a fall at the facility and when she returned the same day, the hospital had accessed her chest wall medication port it was usable to administer R1's IV antibiotic on February 3, 2024. On February 9, 2024, at 2:30 PM, V2 (Director of Nursing) said R1 is the first resident she was aware of that had been in this facility with a chest wall medication port. V2 said when R1's medication port needle came out and when it was realized they did not have the special needles in stock to re-access the site, the physician should have been called. V2 said she was notified they needed to order the needles and she signed the authorization form but thought the nurse had contacted the physician. V2 said she called the pharmacy the day after they faxed the authorization form because they had not received the needles. V2 said she was told by V8 that the pharmacy did not have any and had ordered more needles. Once the pharmacy received their order of needles, they would deliver the facility their order. V2 said when they found out the needles were not going to be available right away, the nurse should notified the physician. On February 9, 2024, at 2:51 PM, V7 (Physician) said he was not aware that R1's chest wall medication port needle had come out and was not aware that the facility did not have the special needles that were needed to access the chest wall medication port. V7 said he was not aware that she was not getting her IV antibiotic and definitely did not know she had missed four doses. V7 said this was a significant concern because of the infection she had and the need for her to get this antibiotic to prevent the infection from worsening. V7 said had if he had known R1's chest wall medication port needle had come out, and the facility didn't have the supplies to access the port, he would have sent R1 to the hospital to have it accessed. 145609 Page 2 of 3 145609 02/10/2024 Hillside Rehab & Care Center 1308 Game Farm Road Yorkville, IL 60560

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On February 9, 2024, at 2:43 PM, V8 (Pharmacist) said he was contacted by the facility needing more needles used to access a chest wall medication port. V8 said the proper authorization was received on January 30, 2024, and he said they would send them the needles. V8 said he spoke with someone from the facility on February 1 and told them they could not fill the order immediately because they were out of their supply of chest wall medication port needles and they needed to be reordered. V8 said they order their supplies on an as needed basis so whoever used the last box of those needles, needed to order more. V8 said the needles were delivered to the facility on February 3, 2024. V8 said it is concerning that a resident went four days without her IV antibiotic. On February 9, 2024, at 2:19 PM, V6 (RN/Registered Nurse) said she was working the evening shift on February 2, 2024, and R1 had been sent to the hospital earlier in the day after she had a fall. V6 said the ER nurse called and asked about her chest wall medication port and V6 said she told the ER nurse that they did not have the needles needed to access her port and R1 had missed four doses of her IV antibiotic. V6 said she told the ER nurse, the needles had been ordered and were supposed to have come on February 2, but they had not arrived. V6 said the ER nurse told her they were sending R1 back to the facility with her port accessed and it would be useable to administer her IV antibiotic. Facility provided their undated policy titled, Medication Administration. This policy showed B. Administration .2. Mediations are administered in accordance with the written orders of the prescriber .D. Documentation . 6. If a dose of a regularly scheduled medication is withheld, refused, not available, .Nursing documents the notification and physician response. 145609 Page 3 of 3