Health inspection·March 20, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a resident received their ordered dose of insulin for 1 of 3 residents (R1) reviewed for insulin administration in the sample of 5. Residents Affected - Few The findings include: R1's Face Sheet shows a diagnosis of: type 1 diabetes mellitus with diabetic polyneuropathy. On 3/20/24 at 8:45 AM, V3 (Registered Nurse) administered R1 his insulin. V3 said R1's blood sugar was 169. V3 placed a needle onto R1's Tresiba insulin pen and turned the dial to 88 units. V3 then drew up 13 units of Novolog insulin. V3 administered both insulins to R1. R1's Physician's Orders sheet, printed on 3/20/24, shows an order for: Tresiba Pen-inject 88 units subcutaneously in the morning for diabetes, Novolog-inject 15 units subcutaneously one time a day for diabetes before breakfast, and Novolog-inject per sliding scale: if 151-200= 2 units (R1's blood sugar was 169 so R1 should have received 17 units of Novolog). On 3/20/24 at 10:58 AM, V3 verified she gave 88 units of Tresiba and 13 units of Novolog. When this surveyor questioned about the Novolog orders, V5 stated, Oh, I read the order wrong and went back and gave him 3 more units of Novolog. R1's Note from his Endocrinologist, dated 2/16/24, shows, Take Novolog 15 units before breakfast, increase to 32 units before lunch and dinner. This note is initialed by V3 with the word done and dated 2/16/24. R1's March Medication Administration Record shows R1 received 30 units of Novolog before lunch and dinner until 3/11/24, and the Novolog was not increased to 32 units before lunch and dinner until 3/12/24 (25 days later). On 3/20/24 at 11:15 AM, V4 (Licensed Practical Nurse) said all insulin pens should be primed with two units before turning the dial to the ordered dose and administering, to ensure the resident gets all of the ordered dose of insulin V4 said the orders should always be double checked before administering the insulin. V4 said if a resident has a scheduled dose of insulin and a sliding scale dose of insulin, it should be calculated how much insulin is to be given based on what the resident's blood sugar was, and should be given at the same time. On 3/20/24 at 1:25 PM, V2 (Director of Nursing) said, If a nurse receives a new written order from the physician, they should put the order into the computer system, write Noted on the paper and sign Page 1 of 2 145702 145702 03/20/2024 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and date it. V2 said she is unsure why R1's insulin order did not get changed since the nurse documented it was done. V2 said it is important to have the right orders entered in the computer for residents who are diabetic and on insulin for the resident's blood sugars to not become too low or too high. V2 said it could be a significant issue if the resident's blood sugars get too high. V2 said insulin pens should always be primed with two units of insulin before administering to ensure the resident receives the full dose of insulin. V2 said if a resident does not receive the full dose of ordered insulin, their blood sugars could increase. V2 said a nurse should check a resident's blood sugar before administering sliding scale insulin and give the resident to ordered dose of insulin based on the blood sugar results, and if they have a regularly scheduled insulin due at that time as well, that dose should be given at the same time as the sliding scale. V2 said the nurses should always follow the doctor's orders for insulin administration. The facility was unable to provide a policy regarding medication/insulin administration. 145702 Page 2 of 2