Health inspection·September 17, 2024

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 observation, interview, and record review the facility failed to ensure a resident received the physician ordered dosage of medication after an order change which applies to 1 of 4 residents (R2) reviewed for pharmacy services in a sample of 4. The finding include: R2's Facility assessment dated [DATE] showed R2 is a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses which includes depression. R2's discontinued Physician Order sheet printed on 9/16/24 showed R2's Doxepin 10 milligrams (mg) order was changed to Doxepin 5 mg on 3/14/24. No other modifications to R2's Doxepin orders were made until 9/12/24. This form showed R2's Doxepin order was changed from 5 mg to 10 mg on 9/12/24. R2's Progress notes dated 3/14/24 showed R2's physician gave a new order to reduce Doxepin to 5 mg. The facility could use the last of the 10 mg doses until the Veterans Affairs (VA) pharmacy could change the medication which could take up to 10 business days. Progress notes dated 3/15/24 showed the pharmacy requested a new order for Doxepin. Doxepin does not come in 5 mg capsules. Doxepin only comes in 3 mg, 6 mg, or 10 mg capsules. Progress Notes dated 4/29/24 showed the VA pharmacy needed a revised script for Doxepin 5 mg to be given in an elixir form. On 9/17/24 at 11:45 AM, V9 Pharmacy Clinical Manager stated Doxepin does not come in a 5 mg dose. It comes in 3 mg and 6 mg tablets and 10 mg, 25 mg and 50 mg capsules. If it needed to be a 5 mg dose it can be made into a 10 mg per milliliter (ml) elixir (suspension). Which could be given at 0.5 ml for the 5 mg dose. On 9/16/24 at 11:30 AM, V4 Registered Nurse (RN) removed R2's Doxepin bottle from the medication cart and one from storage. Both bottles showed Doxepin 10 mg capsules. V4 stated the medication comes in capsules which could not be cut in half like a tablet. V4 stated if a medication and order do not match we need to contact the physician to verify the order, and possibly hold the dose until we get the correct medication. V4 stated R2's Doxepin has always come in 10 mg capsules. V4 stated R4 has never had a liquid version of Doxepin. On 9/16/24 at 12:35 PM, V5 Licensed Practical Nurse stated R2 has always had 10 mg capsule for his Doxepin dose. V5 stated if a medication does not match the order the physician an pharmacy need to be notified so the order can be verified, and the medication can be changed to the correct dose if needed. Page 1 of 2 145727 145727 09/17/2024 Polo Rehabilitation & Hcc 703 East Buffalo Polo, IL 61064

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's undated VA medication list showed R2 received Doxepin 10 milligram (mg) capsules with a last refill date of 7/10/24. On 9/16/24 at 11:45 AM, V2 Director of Nursing stated if a medication order and the medication do not match the physician needs to be contacted to verify the order. The pharmacy also needs to be contacted. In this case the VA provides R2's medications which should have been followed through with for the medication change. V2 stated she was not sure why the when the order changed the medication was not followed up on. The facility's Medication Pass Policy dated 5/2019 showed the five rights for medications administration which includes: verifying the drug against the eMAR (electronic medication administration record) ensuring the label matches the eMAR exactly, and verify the dose in each blister (container) against the eMAR. 145727 Page 2 of 2