Health inspection·April 24, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 ensure the legal representative of a cognitively impaired resident was fully informed regarding the use of psychotropic medications. This applies to 1 of 4 residents (R1) reviewed for psychotropic medications. Residents Affected - Few The findings include: The EMR (Electronic Medical Record) showed R1 is [AGE] years old, with diagnoses that included but not limited to unspecified focal traumatic brain injury, insomnia, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, epileptic seizures related to external causes, not intractable, without status epilepticus, encounter for gastrostomy, catatonic disorder, spondylosis with myelopathy to the cervical region, Vitamin D deficiency, Parkinsonism, quadriplegia, hypertension, and unspecified tremor. The MDS (Minimum Data Set), dated 3/12/2024, showed R1 was moderately impaired with cognition with a BIMS (Brief Interview Mental Status) score of 12/15. The neuropsychology consultation notes, dated 12/20/2021, showed, (R1) neurocognitive profile indicate profound to severe decline in working memory, memory and executive functioning . The consultation notes also showed R1 was identified with diagnoses of major depressive disorder. severe, and major neurocognitive impairment exacerbated by depression. The POA (Power of Attorney) Form, dated 8/30/2021, showed V7 (R1's father) was the designated legal representative/POA of R1. The EMR (Electronic Medical Record) including the POS (Physician Order Sheet) was reviewed with V4 (Psychotropic Nurse). The following psychotropic medications that R1 was administered were identified. V4 also provided copies of psychotropic consents forms for R1. The timeline of psychotropic and antiseizure medications were the following: -Lorazepam 1 mg twice a day; with original order dated 5/6/2022 and with latest order dated 10/5/2023, with same dose. The consent for Ativan was taken on 5/6/2022. The Psychotropic Medication Consent dated 5/6/2022 did not reflect the whether Ativan was anti-anxiety, antidepressant, anti-manic, antipsychotic, hypnotic /sedative. The consent also showed no documentation what specific behaviors that Ativan was used for. The consent form showed whether the consent was obtained via verbal or written and if the POA had agreed with the medications or not. V7 not fully informed for the use of this psychotropic medication since the form were not filled up. The consent form also required the nurse who provided the information; however, the nurse name/signature was blank and did not identify who Page 1 of 3 145638 145638 04/24/2024 Bella Terra Bloomingdale 165 South Bloomingdale Road Bloomingdale, IL 60108

F 0552 provided the information. Level of Harm - Minimal harm or potential for actual harm -Aripiprazole (Abilify) 2 mg daily, ordered on 5/6/2022 following inpatient stay from an acute hospital There was no consent presented regarding the Abilify when started on 5/6/2022. Residents Affected - Few -Increased dosage of Aripiprazole 5 mg daily on 6/25/2022; verbal consent given on 6/25/2022. The psychotropic consent form dated 6/25/2022 showed it was a verbal consent. Again, the consent did not reflect what the specification of this medication, the targeted behavior to justify the use, the side effects, and whether V7 agreed or not with the antipsychotic medication. -Escitalopram 5 mg- ordered on 5/6/2022 following inpatient stay from acute hospital. The consent was not completely filled to ensure V7 was fully informed regarding the drug classification, targeted behavior to justify its medication its use, side effects and whether V7 had agreed or not. -Trileptal 150 mg- started on 7/1/2022 by in house psychiatrist for behavioral outburst and seizure like activity. There was no consent for this mood stabilizer. The current EMAR (Electronic Medical Administration Record) for the month of April 2024 showed R1 was administered the following psychotropic medications: -Aripiprazole (Abilify/antipsychotic) 5 mg. one tablet daily -Ativan 1 mg. (antianxiety medication) two times a day -Escitalopram Oxalate 5 mg. (anit-depressant) daily -Trileptal 150 mg. (mood stabilizer) one tablet daily On 4/22/2024 at 9:48 A.M., V7 was observed next to R1's bedside. V7 stated R1 was given antiepileptic drug before (Keppra) and was discontinued but was given another mood stabilizer/antiepileptic medication which was Trileptal. (R1) does not have epilepsy and seizure disorder diagnosis, and it was a PNES (pseudo non-epileptic seizure). I would like (R1) to be wean from these anti-seizure and psychotropic medications so I can transfer (R1) to another facility that specialize care of patients with TBI (traumatic brain injury) diagnosis like him (R1). This facility does not know how to monitor a TBI patients who have been administered with these medications for prolonged period. The thing about it, was that I was not notified with these medications, the psychotropic and the seizure medication. This Trileptal could cause a detrimental side effect when a patient was weaned off from it. I was not fully informed when these medications. V7 showed copies of consent forms which were issued to him by the facility. The copies were reviewed, and the consents did not show drug classification, what were the targeted behaviors to justify its use, its side effects, and whether V7 had approved of these medications or not. R1 was observed to be non-verbal, but does follow commands by nodding his head, with closed ended simple questions. On 4/22/2024 at 2:00 P.M., V6 (Attending Physician) said R1 had PNES, and Trileptal could be used as a mood stabilizer and anti-seizure medication. On 4/23/2024 at 1:30 P.M., V4 said consent for psychotropic medications should include information of the classification of the drug if it was antianxiety, antipsychotic, hypnotic, or antidepressant. V4 also said the consent should also identify the targeted behaviors to justify the use of the 145638 Page 2 of 3 145638 04/24/2024 Bella Terra Bloomingdale 165 South Bloomingdale Road Bloomingdale, IL 60108

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications and side effects. V4 also stated the consent form should indicate whether the POA had agreed with the use of psychotropic medications. V4 added consent form for the use of psychotropic medications should be completely filled out to ensure the POA was fully informed, and either agreed with these medications or not. The facility's policy psychotropic medication, dated 5/30/2016, showed it is the facility's policy to adhere to federal regulation in use of psychotropic medications . 2. Obtain consent for each psychotropic medication. 145638 Page 3 of 3