Health inspection·April 20, 2023

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 prevent medication errors, which included the dispensing and administration of discontinued medications and the incorrect administration of an antibiotic. This affected three residents (Residents #218, #229, and #274) of five residents sampled for medication errors. The facility census was 74. Residents Affected - Some 1. Review of the physician orders dated 08/17/21 for the Former Specified Resident (FSR) #274, revealed an order for Tramadol tablet, 50 mg (milligrams), four times a day. The physician order for Tramadol, a scheduled IV medication, was discontinued on 08/19/22. Review of the medication error report form dated 08/23/22 revealed the medication was administered in error to FSR #274 on 08/20/22, 08/21/22, and 08/22/22 by specified perpetrator (SP) #391. Review of progress notes for FSR #274 dated 08/24/23 at 8:30 A.M. revealed the family and physician were notified, head to toe assessment was completed, and no new orders were implemented. Review of the controlled narcotic record dated 08/13/22 to 08/22/22, for FSR #274, revealed no discrepancies related to the allegation. Review of the personnel file for Licensed Practical Nurse (LPN) #391 dated 08/31/22, revealed the LPN #391 received education and coaching on the five rights of medication administration. 2. Review of the physician orders dated 03/09/23 for Resident #229, revealed an order for Erythromycin 500 mg tablet, three times a day. Review of the medication error investigation dated 03/09/23 revealed the medication Erythromycin was not administered per the physician order and Azithromycin tablet, 500 mg, was administered once in error to Resident #229 on 03/09/23 LPN #391. Review of progress notes on 03/10/23 for Resident #229, revealed the family and physician were notified, head to toe assessment was completed, and no new orders were implemented. Review of the personnel file for LPN #391 dated 03/17/23, revealed LPN #391 received additional education and coaching on the five rights of medication administration. Interview on 04/17/23 at 10:42 A.M. with Resident #241, revealed no concerns related to medication administration. 3. Review of the physician orders dated 12/15/22 for Resident #218, revealed an order for Xanax, Page 1 of 2 365268 365268 04/20/2023 Altercare of Wadsworth 147 Garfield St Wadsworth, OH 44281

F 0760 Level of Harm - Minimal harm or potential for actual harm 0.5 mg, twice a day as needed for anxiety. The physician order for Xanax, a scheduled IV medication, was discontinued on 03/01/23. Review of the medication error investigation dated 03/29/23 revealed the medication was administered in error to Resident #218 on 08/20/22, 08/21/22, and 08/22/22 by LPN #391. Residents Affected - Some Review of progress notes on 03/29/23 of the Resident #218, revealed the family and physician were notified, head to toe assessment was completed, and no new orders were implemented. Review of the controlled narcotic record dated 02/24/23 to 03/09/23, of Resident #218 revealed no discrepancies related to the allegation. Review of the personnel file for LPN #391 dated 03/20/23, revealed LPN #391 was disciplined for work absences. LPN #391 left the building and did not return to the facility. Interview on 04/17/23 at 2:55 P.M. of the Director of Nursing (DON), revealed she confirmed the medication administration errors. The DON further revealed on 03/20/23 after a disciplinary action, LPN #391 did not return to the facility. This deficiency represents non-compliance investigated under Complaint Number OH00139439. 365268 Page 2 of 2