Health inspection·April 13, 2023

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 ensure a resident received medications as ordered by the physician. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], and had a planned discharge to home on March 29, 2023. R1 had multiple diagnoses including fracture of the superior [NAME] of the left pubis, heart failure, chronic kidney disease, obesity, hypertension, and unsteadiness on feet. R1's MDS (Minimum Data Set), dated March 17, 2023, shows R1 was cognitively intact, able to eat with supervision, and required extensive assistance with all other ADLs (Activities of Daily Living). R1 was always incontinent of bowel and bladder. The EMR shows the following order for R1: Vancomycin HCl (Hydrochloride) (antibiotic medication) 125 mg. (Milligram), Give 1 capsule by mouth four times a day for C-Diff (Clostridium Difficile) colitis for 10 days. The medication was ordered by V5 (ID-Infectious Disease NP-Nurse Practitioner) on March 24, 2023. R1's MAR (Medication Administration Record), dated March 1 to March 31, 2023, shows R1 did not receive the medication as ordered on the following dates: March 24, 2023 at 5:00 PM - V7 (Agency Nurse) documented see nurse's notes March 25, 2023 at 12:00 PM - V8 (Agency Nurse) documented unavailable March 25, 2023 at 5:00 PM - V8 documented unavailable March 25, 2023 at 9:00 PM - V8 documented unavailable March 26, 2023 at 9:00 AM - V9 (RN-Registered Nurse) documented see nurse's notes March 26, 2023 at 12:00 PM - V9 documented see nurse's notes March 26, 2023 at 5:00 PM - V10 (Agency RN) documented see nurse's notes Page 1 of 4 145737 145737 04/13/2023 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0760 March 26, 2023 at 9:00 PM - V10 documented S (Sleeping) Level of Harm - Minimal harm or potential for actual harm March 27, 2023 at 9:00 AM - V11 (Nurse) documented unavailable March 27, 2023 at 12:00 PM - V11 documented unavailable Residents Affected - Few March 27, 2023 at 5:00 PM - V12 (Agency RN) documented unavailable On March 24, 2023 at 5:15 PM, V7 (Agency Nurse) documented, Vancomycin HCl oral capsule 125 mg .not delivered yet and not in [emergency box]. On March 25, 2023 at 12:13 PM, V8 (Agency Nurse) documented, Vancomycin HCl oral capsule 125 mg .not yet available from pharmacy. On March 25, 2023 at 4:39 PM, V8 (Agency Nurse documented, Vancomycin HCL oral capsule 125 mg .unavailable at this time. On March 26, 2023 at 9:27 AM, V9 (RN) documented, Vancomycin HCl oral capsule 125 mg .not available on order per HS (Hour of Sleep) RN report. On March 26, 2023 at 12:35 PM, V9 (RN) documented, Called [V3] (Pharmacy Technician) from [pharmacy] to order more Vancomycin. Said med was received 3/25 5:41 AM by [V13] (Nurse). I cannot locate med. On March 26, 2023 at 1:18 PM, V9 (RN) documented, Vancomycin HCl oral capsule 125 mg .n/a (Not Available). On March 26, 2023 at 6:38 PM, V10 (Agency RN) documented, Vancomycin HCl oral capsule 125 mg .Called Rx. Please see progress note. The facility does not have documentation to show V10 entered a progress note regarding R1's Vancomycin. On March 27, 2023 at 4:13 PM, V12 (Agency RN) documented, Vancomycin HCl oral capsule 125 mg med unavailable. On April 12, 2023 at 1:02 PM, V5 (Infectious Disease Nurse Practitioner/ID NP) said, [R1] was experiencing loose, watery stools multiple times a day. The stool sample we obtained from her on March 21, 2023 showed she tested positive for the C-Diff antigen, and negative for the C-Diff toxin. Those results were reported to the facility on March 22, 2023 at 7:08 PM. If a resident tests positive for the antigen, but negative for the toxin, we still treat the resident with Vancomycin if the resident is symptomatic. [R1] was very symptomatic, with multiple loose, watery stools and abdominal cramping. The oral medication is given four times a day to treat the symptoms. I was not notified by the nursing staff regarding a delay in [R1] receiving the Vancomycin as ordered. Missing almost four days of the medication is a severe delay in care. Not treating C-Diff can lead to multiple complications for residents, including sepsis. The medication should have been started right away and administered as ordered. The EMR shows the following order for R1, ordered March 10, 2023: Allopurinol oral tablet 200 mg. Give 1 tablet by mouth one time a day for gout. The EMR continues to show Start date: 3/11/2023 0900 (9:00 AM). Date dispensed: 3/22/23. 145737 Page 2 of 4 145737 04/13/2023 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0760 The pharmacy delivery manifest, dated March 22, 2023, shows R1's Allopurinol was delivered to the facility on March 22, 2023 at 3:38 PM. Level of Harm - Minimal harm or potential for actual harm R1's March 2023 MAR shows the following documentation for R1's Allopurinol medication: Residents Affected - Few March 11, 2023 at 9:00 AM - V14 (Agency RN) documented unavailable March 12, 2023 at 9:00 AM - V9 (RN) documented see nurse's notes March 13, 2023 at 9:00 AM - V15 (Agency RN) documented see nurse's notes March 14, 2023 at 9:00 AM - V6 (Nurse) documented the medication was administered to R1 despite the medication not being available/delivered until March 22, 2023. March 15, 2023 at 9:00 AM - V6 (Nurse) documented the medication was administered to R1 despite the medication not being available/delivered until March 22, 2023. March 16, 2023 at 9:00 AM - V16 (Agency RN) documented unavailable March 17, 2023 at 9:00 AM - V6 (Nurse) documented the medication was administered to R1 despite the medication not being available/delivered until March 22, 2023. March 18, 2023 at 9:00 AM - V16 (Agency RN) documented unavailable March 19, 2023 at 9:00 AM - V8 (Agency LPN-Licensed Practical Nurse) documented unavailable March 20, 2023 at 9:00 AM - V11 (Nurse) documented the medication was administered to R1 despite the medication not being available/delivered until March 22, 2023. March 21, 2023 at 9:00 AM - V9 (RN) documented the medication was administered to R1 despite the medication not being available/delivered until March 22, 2023. March 22, 2023 at 9:00 AM - V9 (RN) documented see nurse's notes On March 12, 2023 at 10:16 AM, V9 (RN) documented, Allopurinol oral tablet 200 mg .remains unavailable at this time. On March 18, 2023 at 9:03 AM, V16 (Agency RN) documented, Allopurinol oral tablet 200 mg .not available from pharmacy. On March 22, 2023 at 10:53 AM, V9 (RN) documented, Ordered Allopurinol and Eliquis from [Pharmacy]. On April 12, 2023 at 10:41 AM, V3 (Pharmacy Technician) said, The Allopurinol 200 mg. ordered on March 10, 2022 was not dispensed until March 22,2023. We sent a clarification order to the facility because the medication only comes in 100 mg. or 300 mg. tablets, and we wanted to make sure the dose was 200 mg. and to see if the physician wanted the resident to receive two 100 mg. tablets for each dose. We called the nurse's station, and no one answered us. We also sent a message for dose clarification but never received a response from the facility. Finally, on March 22, 2023, [V9] (Registered Nurse/RN) gave us the okay to send two tablets of the 100 mg. to make the 200 mg. dose for the 145737 Page 3 of 4 145737 04/13/2023 Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident. The facility does not keep this medication in their convenience box so the medication would not have been available to administer to the resident until it was delivered on March 22, 2023. On April 12, 2023 at 2:07 PM, V4 (Pharmacist) said, Allopurinol does not come in 200 mg. tablets, so we needed a dose clarification before we could send the medication. The medication is to treat gout. The medication is used as a maintenance medication, not for an acute gout attack. Whether or not a resident could end up having a gout attack due to missing the medication for twelve days would be very patient specific depending on their gout history. The clarification notice would go to the nurse on the unit. Some buildings have an escalation protocol they are supposed to follow when medications are missing or need clarification. This facility does not have that process in place. The facility does not have documentation to show R1's physician was notified R1 did not receive the Vancomycin and Allopurinol as ordered and the medications were unavailable from pharmacy or missing. On April 12, 2023 at 2:52 PM, V2 (DON/Director of Nursing) said, I was not aware the resident did not receive her Vancomycin or Allopurinol. No one told me she was missing the medications. Order clarifications get sent to the first-floor fax machine and the nurses take if off and are supposed to follow up. If you are missing a medication, you should call the pharmacy. I cannot answer why that process was not followed. On April 12, 2023 at 2:55 PM, V1 (Administrator) said the expectation of the staff is to call the pharmacy to determine the location of the missing medications. The facility provided the following policy regarding missing medications entitled Unavailable Medications dated 09-2018, revision date 08-2020: The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2. Obtain a new order and cancel/discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. 145737 Page 4 of 4