Health inspection·January 10, 2025

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 provide medication as ordered by the Physician. This applies to 1 resident (R1) of three reviewed for medication administration in a sample of three. Residents Affected - Few Findings include: R1's medical diagnosis from the electronic medical record documents R1 as an [AGE] year-old with diagnoses to include Vascular Dementia with severe agitation. On 01/09/2025 at 12:29 PM V2 (Director of Nursing) stated On the second, (01/02/2024) in the afternoon (R1) was having a meltdown. He was striking staff and asking who we are going to murder. The nurse asked me to assist her with drawing up his PRN (as needed) medication. It was an intense situation. Instead of going to the MAR (medication administration record) I asked her what dose of Haldol he was receiving. Her response was 2ml (milliliters). I went to the med cart drew up the 2ml and gave it. It calmed him down eventually. He had a seat and kept busy with adjusting and messing with a wheelchair. There was no drowsiness or sedation. The Physician was present during the interaction and witnessed the resident before and after the medication administration. On 01/09/2025 at 1:59 PM at 10:53 AM V7 (Licensed Practical Nurse/LPN) stated (R1) was very violent and redirection was not changing his demeanor. Once (V2 Director of Nursing) gave him the medication he quit striking us. He remained up on the unit the entire afternoon and evening. The Physician Order for R1 dated 12/31/2024 lists haloperidol lactate solution, 5 mg (milligrams)/mL; amt: 2 MG; injection every six hours as needed. (The drug classification for this medication is miscellaneous antipsychotic agent.) The Medication Administration Record for R1 dated 01/02/2025 at 3:18 PM documents the PRN (as needed) being administered. The Medication Administration policy which is not dated documents under VIII; Compare the licensed practitioners prescription/order with MAR (medication administration record). Listed under iX; Compare the licensed practitioners order with the pharmacy label on the medication package. Listed under X; Compare the pharmacy label and MAR. XI; Any discrepancies identified during the first, second, and /or third check must be resolved prior to the administration of any medication. On 01/09/2025 at 2:44 PM V13 (Nurse Practitioner) stated Yes, this was a medication error. The doctor was there during (R1's) outburst. He witnessed the entire episode and yes, we did speak of the situation. The amount of Haldol (R1) received was not enough to cause any harm. In fact, it barely Page 1 of 2 145985 145985 01/10/2025 Evercare at University 1095 University Drive Edwardsville, IL 62025

F 0760 slowed his behaviors. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145985 Page 2 of 2