Health inspection·August 18, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, record review, and facility policy review the facility did not ensure insulin was dated after it was opened and/or failed to ensure the insulin was labeled with the resident's name after it was pulled from the contingency box. This affected three residents (#44, #45 and #59) out of nine residents who had orders for insulin on the C North medication cart. This had the potential to affect 20 residents (#6, #9, #14, #16, #27, #29, #30, #32, #35, #44, #45, #47, #50, #52, #55, #59, #60, #74, #80, and #85) who had orders for insulin at the facility. Findings included: 1. Review of the medical record for Resident #44 revealed an admission date of 04/14/23 with diagnoses including diabetes, chronic obstructive pulmonary disease, and heart failure. Review of the August 2023 physician orders revealed Resident #44's orders included: Novolog FlexPen 100 units per milliliter (ml) inject 35 units subcutaneously (SQ) before meals and Ozempic pen-injector 2 milligram (mg) per 1.5 ml inject 0.25 mg SQ every seven days in the morning. Observation on 08/18/23 at 9:06 A.M. revealed Licensed Practical Nurse (LPN) #602 opened a new Novolog insulin FlexPen and administered Resident #44's 35 units SQ to his right upper arm per his order. She placed the new insulin FlexPen back into the medication cart without labeling with the date that she had opened. Observation of the C North medication cart with LPN #602 on 08/18/23 at 10:06 A.M. revealed Resident #44's Novolog continued to be not dated. Observation revealed there was an opened Ozempic insulin pen that was undated as to when it was opened and without a name to who the insulin pen belonged to. Interview on 08/18/23 at 10:06 P.M. with LPN #602 verified she had forgot to date the Novolog insulin for Resident #44 when she opened it. She also verified the Ozempic insulin pen was unlabeled with name of resident and/ or date when opened. She revealed she did not know who the Ozempic pen belonged to. Interview on 08/18/23 at 10:08 A.M. with the Director of Nursing (DON) as she walked by the C North medication cart verified the Ozempic pen was unlabeled as there was no identification of a resident's name on the pen and/ or a date of when the pen was opened. She revealed the pen was pulled from the contingency box and should have been labeled with the resident name and dated when opened. Page 1 of 2 365129 365129 08/18/2023 Eastbrook Healthcare Center 17322 Euclid Ave Cleveland, OH 44112

F 0761 Interview on 08/18/23 at 2:31 P.M. with the DON verified the Ozempic pen belonged to Resident #44. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #59 revealed an admission date of 03/25/21 with diagnoses including acute respiratory failure with hypoxia and diabetes. Residents Affected - Few Review of the August 2023 physician orders revealed Resident #59 had a physician order for Novolog FlexPen 100 units per ml inject per sliding scale SQ. Observation on 08/18/23 at 9:25 A.M. revealed LPN #602 administered Resident #59's Novolog insulin 10 units to her left upper arm per her sliding scale. The insulin pen was not dated as to when it was opened. Interview on 08/18/23 at 9:34 A.M. with LPN #602 verified that the insulin pen was not dated as to when it was opened and that she had not checked the pen prior to administering Resident #59 her insulin. 3. Review of medical record for Resident #45 revealed an admission date of 08/27/16 with diagnoses including diabetes and hypertension. Review of the August 2023 physician orders revealed Resident #45 had an order for Humalog Kwik pen solution 100 units per ml per sliding scale. Observation of the C North medication cart with LPN #602 on 08/18/23 at 10:06 A.M. revealed there was a Humalog insulin vial approximately one fourth full of a date as opened as 08/01/23 but the vial did not have a resident's name on the vial. Interview on 08/18/23 at 10:06 P.M. with LPN #602 verified the Humalog vial did not have a resident's name on it to identify who the insulin belonged to. Interview on 08/18/23 at 10:08 A.M. with the DON as she walked by the C North medication cart verified the Humalog vial was pulled from the contingency box and was not labeled properly with a resident's name of who the insulin belonged to. Interview on 08/18/23 at 2:31 P.M. with the DON verified the Humalog belonged to Resident #45 as they had pulled the insulin from the contingency box for him. Review of the facility policy labeled, Administering Medications, dated April 2019, revealed medications were to be administered in a safe and timely manner. The policy revealed the expiration date on the medication was checked prior to administering and when opening a multi-dose container, the date opened was to be recorded on the container. The policy revealed insulin pens containing multiple doses of insulin were for single-resident use only. The policy revealed insulin pens were clearly labeled with the resident's name or other identifying information prior to administering the insulin. This deficiency represents non-compliance investigated under Complaint Number OH00144529. 365129 Page 2 of 2