Health inspection·August 15, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure residents are free from significant medication errors, by failing to correctly identify a resident prior to medication administration. This failure affects one resident (R1) out of seven reviewed for medication administration. Residents Affected - Few Findings include: R1's Face Sheet (undated) electronic Census Detail documents R1 was admitted to the facility for this residency on 9/28/23. R1's (undated) electronic Diagnoses List documents R1 experienced medical conditions including Congestive Heart Failure, Atrial Fibrillation, History of Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, Anxiety, Hypertension, Coronary Artery Disease, and major Depression. R1's emergency room After Discharge Instructions dated 8/8/24 documents R1 was treated at the emergency room for an accidental medication overdose, requiring intravenous fluids, administration of intravenous Vitamin K 5 milligrams (mg) to reverse the effects of Coumadin (anticoagulant, blood thinner), 1,000 milliliters of normal saline, and oral administration of Vitamin B-12 5 mg. On 8/15/24 at 10:30 AM, V2, Director of Nursing, stated, I was training a new nurse (V3, Licensed Practical Nurse), it was her second day working here. R1 had a room change the night before and his nameplate had not been moved to his new room where he became a roommate of (R2). V2 continued, (V3) got to the room of (R2) and prepared (R2's) medications. R2's name was the only one on the door but it was (R1) who was actually in the room at the time. V2 further stated, (V3) gave (R2's) medications to (R1), this was the HS (bedtime) medications and was around 2100 (9:00 PM). I did counsel (V3) that we don't just go by the name on the door, we have to look at the pictures in the charts, and that most of our residents can identify themselves by name. V2 continued, We did end up sending (R1) to the emergency room and they did give (R1) some Vitamin K, saline, and B-12. V2 concluded by stating, (R1) came back here in just a few hours. R1's (undated) Electronic Medical Record picture portrayed a standing, tall, thin, caucasian man with clean shaven face. R2's (undated) Electronic Medical Record picture portrayed a much shorter, rotund, african american man with a gray beard seated in a wheelchair. R2's (undated) current electronic Physician Order Sheet documented R2 receives HS medications including Coumadin 5.5 mg in a combination of a 3 mg tablet and a 2.5 mg tablet (anticoagulant), Trazadone 100 mg (antidepressant sedative), Lyrica (gabalin analogue, calms overactive nerves, nerve pain, muscle pain, seizures), Oxcarbazepine 300 mg (anticonvulsant, antiseizure), and Atorvastatin 20 mg (lowers cholesterol). These medications were confirmed with V2 as having been included in the medications incorrectly administered to R1. Page 1 of 2 146050 146050 08/15/2024 The Haven of Arcola 422 East Fourth Street Arcola, IL 61910

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's (undated) electronic current Physician Order Sheet (POS) documented R1 did not have physician orders for any of the medications administered to R1 on 8/8/24. This same POS documents R1 does have physician orders for Apixaban (anticoagulant) 5 mg twice daily at 8:00 AM and 4:00 PM making a duplicitous medication therapy when given with R2's Coumadin at 9:00 PM. This same POS documents R1 does have physician orders to receive Sertraline 50 mg daily (antidepressant) also duplicitous when administered with R2's Trazadone. This POS documents R1 has physician orders to receive Buspirone (antianxiety) 5 mg twice daily at 8:00 AM and 4:00 PM having additive effects when administered with R2's Trazadone, Lyrica, and Oxcarbazepine. The facility Medication Administration Policy dated revised 11/18/17 documents, Medications must be identified by using the seven (7) rights of administration: Right resident, Right drug, Right dose, Right consistency, Right time, Right route, Right documentation. This same policy documents, Identify each resident prior to medication administration. Two methods of verification must be utilized prior to administration of a medication: Check photograph, Ask resident his/her full name, Verify resident's identity with another employee familiar with the resident, Call the resident by name and ask for confirmation. 146050 Page 2 of 2