Health inspection·June 9, 2023

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. Based on interview and record review the facility failed to transcribe a physician order to the resident's Physician Order Sheet to ensure medications are administered as ordered for 1 of 1 resident (R2) reviewed for pharmaceutical services in the sample of 4. Findings include: R2's admission Nursing Assessment, dated 5/2/23, documented diagnoses of Atrial flutter, Prolonged heart QT waves, Dementia, and Hypertension. R2's Physician's Order, dated 5/2/23, documents Eliquis 5 milligrams tablet twice a day and scheduled for 8:00AM and 5:00PM for Atrial Flutter of the heart. On 6/7/23 at 2:10 PM, V3 Licensed Practical Nurse, LPN, stated that R2 had blood in her adult incontinent brief. V3 stated she telephoned V4, R2's Physician, on 5/27/23 at 7:15 AM, regarding R2's blood in stool. V3 stated she received a verbal telephone order from V4 to hold R2's Eliquis for the 8:00AM scheduled dose and order a STAT (immediate) hemoglobin and hematocrit (H&H) blood draw and then to notify V4 when the lab results came back. V3 stated she held the 8:00 AM Eliquis scheduled dose as ordered, obtained R2's blood sample and sent off to the laboratory immediately. V3 stated the results of the H&H results came back to the facility within a few hours. V3 stated she notified V4 by telephone and received an order to continue R2's Eliquis as scheduled. V3 stated she documented on the Medication Administration Record (MAR) to hold the one single 8:00AM dose; however, failed to transcribe on R2's Physician's Order Sheet (POS), to continue/resume R2's Eliquis scheduled dosage twice a day. R2's Skilled Progress Note, dated 5/27/23 at 7:15AM, written by V3 documented, N.O (New order) received from V4. Please see POS (Physician Order Sheet). The Note documented Resident had large copious amount of blood in depends in her stool this morning. R2's, POS, dated 5/27/23, un-timed and written by V3, documents1.) STAT emergency laboratory draw for H&H blood draw. 2.) Hold Eliquis until H&H result called to V4. 3.) ok to send to ER (emergency room) for evaluation and tx. (treatment) if another bleeding episode occur. R2's, Skilled Progress Note, dated 5/27/23 at 10:15AM, documented V4 was called regarding R2's H&H results and V4 said to continue Eliquis and watch resident if she has another bleeding episode or continues not to eat or drink all day as V4 would recommend her to be evaluated by Emergency Department and follow-up with V6, R2's physician. Page 1 of 2 145851 145851 06/09/2023 Eastside Health and Rehabilitation Center 1400 East Washington Street Pittsfield, IL 62363

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's May 2023 MAR, documented, HOLD, written in the 8:00AM check box for the Eliquis, initialized by V3, who received the order. The MAR documented that R2 received the 5:00 PM dose. The MAR documented R2 did not receive Eliquis on 5/28/23. R2's June 2023 MAR, documented R2 did not receive Eliquis on 6/1 and 6/2/23. The MAR documented HOLD on 6/2/23. On 6/7/23 at 2:46 PM, V7, LPN stated, she documented in the MAR on 6/1/23 that R2 did not receive her 8:00AM and 5:00 PM dose of Eliquis, as this was reported to her from a previous nurse reporting off work that R2's Eliquis is not to be given, and stated she wrote the word hold, on the MAR for the following day, 6/2/23. V7 stated she assumed that since R2 had rectal bleeding not to give the Eliquis (blood thinner) and failed to follow-up with the physician on clarification of the medication order and did not follow-up to look in R2's POS of a medication order change. On 6/7/23 at 3:40PM, V5, Registered Nurse for V6's (R2's Physician), stated that V6 did not order to discontinue R2's Eliquis. On 6/8/23 at 12:00PM, V1, Administrator, stated she would expect the nursing staff to document and process physicians order when received. The facility's policy and procedure, entitled, Pharmacy Medication Orders and Resident's Charts, dated 10/06, documents, Telephone orders are to be written on the special Physician's Telephone Orders form, and signed by the nurse taking the order. Whenever possible, the licensed nurse receiving the physician order should completely transcribe the order before returning the chart to the rack. Transcription includes transcribing the order to the following: The POS, MAR. All orders must include complete directions, including frequency, special directions. 145851 Page 2 of 2