Health inspection·February 13, 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 observation, interview, and record review, the facility failed to follow physician orders when administering medications including multiple doses of intravenous antibiotics for two (R7, R8) residents out of three residents reviewed for medication administration in a sample list of eight residents. Residents Affected - Few Findings include: 1. R7's Electronic Medical Record (EMR) documents medical diagnoses as Multiple Sclerosis, Heart Failure, Epilepsy, Acute Osteomyelitis, Sacral Pressure Ulcer, Need for Personal Care, and Bacteremia. R7's Minimum Data Set (MDS), dated [DATE], documents R7 as cognitively intact. R7's Physician Order Sheet (POS), dated February 2025, documents a physician order starting 2/1/25 for Ertapenem Sodium one Gram (GM) every 24 hours intravenously for wound infection until 2/3/25. This same POS documents a physician order starting on 2/3/25 for Ertapenem Sodium one gram (gm) every 24 hours intravenously for wound infection until 2/11/25. Notify Physician if medication is missing. R7's Medication Administration Record (MAR), dated February 2025, documents R7 was not administered Ertapenem Sodium One GM on 2/1/25, 2/2/25, 2/5/25, 2/8/25 and 2/10/25. R7's Nurse Progress Notes do not document R7's Ertapenem Sodium One Gram (GM) not being administered on 2/1/25, 2/2/25, 2/5/25, 2/8/25 and 2/10/25. R7's Nurse Progress Notes do not documents notifications being made to R7's Physician, R7, nor R7's Power of Attorney (POA). R7's Medication Error Report, dated 2/3/25, documents R7's Ertapenem Sodium One GM was not administered on 2/1/25 and 2/2/25 due to staff not being able to locate the medication. The facility was unable to provide medication error reports due to R7's Ertapenem Sodium not being administered on 2/5/25, 2/8/25 and 2/10/25. On 2/11/25 at 1:00 PM, R7 was laying in his bed with a Peripherally Inserted Central Catheter (PICC) line in place in his Left Upper arm. On 2/11/25 at 1:05 PM, R7 stated the nurses are 'hit an miss' administering his Ertapenem Sodium One Gram (GM) via his PICC (peripherally inserted central catheter) line. R7 stated, Sometimes they (staff) are good about it and other times I have to wait for hours. Then I ask about it and they tell me they will get it. No one ever returns to give me the antibiotic. That is the entire reason I have to have this PICC line. If they (staff) aren't going to give it to me, then I should not have to Page 1 of 3 146162 146162 02/13/2025 Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have this PICC line. Now I was told that I have to have it (IV antibiotic) for more days due to the staff didn't give it right. That isn't right. On 2/11/25 at 1:45 PM, V7, Agency Registered Nurse (RN), stated she worked on 2/1/25 and 2/2/25 as R7's nurse. V7 RN stated she looked for R7's Ertapenem Sodium IV antibiotic, but was not able to find it. V7, RN, stated she did not give R7's antibiotic on those two days, and did not notify the Physician. V7, RN, stated she was told later that the facility has a back up medication storage system, which did include the antibiotic, which was onsite that weekend. V7, RN, stated, I guess I should have called somebody, but I can't be expected to give something I can't find. I should not have to call the doctor every time someone doesn't get their medication. 2. R8's Electronic Medical Record (EMR) documents medical diagnoses of Epilepsy and Dementia. R8's Minimum Data Set (MDS), dated [DATE], documents R8 as severely cognitively impaired. R8's Physician Order Sheet (POS), dated December 2024, documents a physician order starting 12/6/24 for Briviact Oral Tablet 50 milligram (MG). Give 50 mg by mouth two times a day for Epilepsy. R8's Medication Administration Record (EMR), dated December 2024, documents R8 received the scheduled doses of Briviact 50 mg in the morning and evening of 12/17/24. R8's Nurse Progress Note, dated 12/17/24 at 8:04 PM, documents R8 was given the wrong dose of Briviact (anti-epileptic) medication. This same note documents, (R8) was mistakenly given two doses from a card of another resident with 100 milligram (mg) Briviact, though (R8) is ordered 50 mg of Briviact. R8's Medication Error Report, dated 12/17/24, documents R8 received the wrong dose of Briviact. This same report documents R8 was ordered 50 mg Briviact twice daily and was mistakenly given Briviact 100 mg on 12/17/24. On 2/11/25 at 3:00 PM, V5, Nurse Practitioner (NP), stated R7's Intravenous (IV) antibiotic Ertapenem Sodium One GM was ordered daily for R7's Sacral Pressure Ulcer, which is infected. V5, NP, stated Ertapenem wound be considered a critical medication necessary for R7's wound healing. V5, NP, stated V5 is not aware R7 had any side effects from the staff not administering this medication, but 'absolutely could have'. V5, NP, stated there is no excuse for V7, Agency Registered Nurse (RN), to not call V5, NP, on 2/1/25 to report R7's medication could not be located. V5, NP, stated the facility did in fact have R7's Ertapenem, which was in the Stat Safe medication storage system. V5, NP, stated she found out R7 did not have his Ertapenem on 2/3/25. V5, NP, stated V5 is onsite five days per week for half days, which is during the time R7 is scheduled to receive his IV antibiotic through his PICC line. V5, NP, stated the staff could have notified her while she was in the building, and she would have addressed the situation immediately. V5, NP, stated R8 has Briviact 50 mg ordered twice daily for his Seizure Disorder. V5, NP, stated all residents medications should be administered as ordered by the prescriber. V5, NP, stated V6, Agency Licensed Practical Nurse (LPN), mistakenly administered Briviact 100 mg to R8. V5, NP, stated R8 did not have any significant medical complications due to this error. V5, NP, stated, (R8) was lucky to not have any significant issues due to this error. It could have been much worse. Overdosing the resident's neurological symptoms could cause ill effect. On 2/13/25 at 10:05 AM, V1, Administrator, stated the facility does not have a policy or guidelines 146162 Page 2 of 3 146162 02/13/2025 Moweaqua Rehab & Hcc 525 South Macon Street Moweaqua, IL 62550

F 0760 Level of Harm - Minimal harm or potential for actual harm on medication errors. V1 stated it is the expectation for nursing staff to follow the physician orders, and if there a reason a resident does not get their medication or gets the wrong dose, then the staff should reach out to the provider. Residents Affected - Few 146162 Page 3 of 3