Health inspection·October 11, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 2 of 3 (R2, R4) residents reviewed for viral infections in the sample of 3 were administered the correct dose of antiviral medications. This failure resulted in R2 being hospitalized for 21 days and R4 having significant side effects. Residents Affected - Few The findings include: 1. On 10/11/24 at 12:10 PM, V6, Nurse Practitioner (NP), said R2 was diagnosed with shingles and was put on Valtrex (an antiviral), 1 gram (1000 milligrams) three times a day for seven days, which is a standard dose for shingles. V6 said R2 dose should have been adjusted because he is a dialysis patient. R2's dose should have been 500 milligrams (mg) three times a day for seven days. V6 said she does not know why it was not adjusted; it just did not get adjusted. V6 said signs and symptoms of a Valtrex overdose would include confusion and delirium. V6 said R2 was sent to the hospital for low blood glucose but admits that part of it could have been that he had extra Valtrex in his system. V6 said patients with renal (kidney) problems should be given doses of antiviral medications (like Valtrex) based on their creatinine clearance (labs indicating kidney function). On 10/11/24 at 2:25 PM, V2, Director of Nursing, said R2 was admitted to the hospital (on 9/14/24) with altered mental status. V2 said R2 had been receiving Valtrex. V2 said it is his understanding that the NP put in an order for regular dosing versus renal dosing, and R2 was dependent on renal dialysis. V2 said the Valtrex dosing contributed to R2's hospitalization as there are precautions for Valtrex affecting renally impaired patients. V2 said signs and symptoms of Valtrex overdose include hallucinations and decreased mentation. V2 said R2's Valtrex dosage was larger than R2 could tolerate. R2's admission Record dated 9/24/24 shows R2's diagnoses include, but are not limited to, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic disease, or end stage renal disease, congestive heart failure, end stage renal disease, and dependence on renal dialysis. R2's Order Summary Report dated 10/11/24 shows and order dated 9/9/24 for Valacyclovir (Valtrex) one gram by mouth every eight hours for cold sores, shingles, or genital herpes for seven days. R2's Medication Administration Record (MAR) for 9/1/24 to 9/30/24 shows R2 began receiving the prescribed Valtrex at 2:00 PM on 9/9/24 and received 12 doses from 9/9/24 to 9/14/24. R2's Progress Notes dated 9/14/24 at 11:57 AM show R2 was lethargic and slow to respond. R2 was sent via ambulance to the hospital. R2's Progress Notes dated 9/14/24 at 9:55 PM show R2 was admitted to the hospital with a diagnosis of altered mental status. R2's History and Physical (H&P) date of service 9/15/24 at 5:28 PM, shows R2 presented to the hospital with altered mental status with minimal responsiveness, herpes simplex infection of the chest wall, and end stage renal disease requiring Page 1 of 2 145630 145630 10/11/2024 Elevate Care North Branch 6840 West Touhy Avenue Niles, IL 60714

F 0760 Level of Harm - Actual harm Residents Affected - Few hemodialysis. R2 had been receiving antivirals orally but he was getting 1 gram instead of the 500 mg for renal dose adjustment. Under the Assessment/Plan of the H&P the physician documented the following: Altered mental status most probably metabolic multifactorial secondary to the high dose of acyclovir and missing his scheduled dialysis on 9/14. R2's hospital Progress Note, date of service 10/3/24 at 5:40 PM, shows . toxic encephalopathy related to acyclovir toxicity present on admission . R2's After Visit Summary dated 10/5/24 show R2 was hospitalized from [DATE] to 10/5/24 with a diagnosis of altered mental status. 2. On 10/11/24 at 11:38 AM, R4 said he had shingles and was treated with Valtrex. R4 said he remembers getting dizzy when he was taking the Valtrex and felt much better once it was discontinued. R4's admission Record dated 10/11/24 shows his diagnoses include, but are not limited to, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic disease, or end stage renal disease, congestive heart failure, end stage renal disease, and dependence on renal dialysis. R4's Order Summary Report dated 10/11/24 shows R4 was prescribed valacyclovir (Valtrex) one gram by mouth three times a day for seven days on 9/18/24. R4's Progress Notes from 9/24/24 at 11:52 AM show multiple staff report R4 is having bouts of confusion and hallucinations which have increased since he began taking Valtrex. R4's Progress Notes from 9/24/24 at 12:07 PM show R4 was observed with confusion. R4's MAR for 9/1/24 to 9/30/24 shows R4 received Valtrex one gram beginning on 9/18/24 at 2:00 PM and continued to receive an additional five doses before the medication dosage was reduced to 500 mg once a day. On 10/11/24 at 2:25 PM, V2, Director of Nursing, said the Valtrex dosing was improper. V2 said R4 was not originally given a renal dose of his Valtrex. V2 said R4 developed hallucinations after receiving Valtrex, so it was discontinued. V2 said it is the providers responsibility to order the proper dosage of medications. The facility's Administration Procedures for all Medications Policy (effective 10/25/2014) shows it is their policy to administer medications in a safe and effective manner. 145630 Page 2 of 2