Health inspection·April 12, 2023

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 medical record review, observation, staff interview, and review of the manufacturers recommendations, the facility failed to ensure residents were free from significant medication errors when an insulin pen was not primed prior to administration. This affected one resident (#43) out of 10 residents observed for medication administration. The facility identified 12 residents who received insulin pens in the facility. The facility census was 69. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed an admission date of 03/18/20. Diagnoses included type two diabetes mellitus, major depressive disorder, atrial fibrillation, and anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. Review of the care plan dated 08/02/22 revealed Resident #43 had a diagnosis of diabetes mellitus. Interventions included diabetes medication as ordered by the physician and observe for side effects and effectiveness. Staff to monitor fasting serum blood sugar as ordered by the physician. Review of the physician order dated 11/16/22 revealed Resident #43 was ordered Humalog KwikPen Solution Pen-injector 100 unit/milliliter (ml). Inject as per sliding scale: If blood sugar was 181 milligram per deciliter (mg/dL) to 200 mg/dL give one unit If blood sugar was 201 mg/dL to 250 mg/dL give two units If blood sugar was 251 mg/dL to 300 mg/dL give four units If blood sugar was 301 mg/dL to 350 mg/dL give six units Page 1 of 4 365277 365277 04/12/2023 Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013

F 0760 - Level of Harm - Minimal harm or potential for actual harm If blood sugar was 351 mg/dL to 400 mg/dL give eight units - Residents Affected - Few If blood sugar was 401 mg/dL to 450 mg/dL give 10 units If blood sugar was greater than 451 mg/dL give 10 units and call the physician Observation on 04/11/23 at 6:08 A.M. revealed Licensed Practical Nurse (LPN) #24 gave Resident #43 Lispro insulin using an insulin Pen. LPN #24 did not prime insulin pen prior to administering insulin to Resident #43. LPN #24 dialed insulin pen to one unit and administered the insulin, which is what Resident #43 received with a blood sugar of 194 mg/dL per sliding scale orders. Interview on 04/11/23 at 6:26 A.M., with LPN #24 verified he had not primed the insulin pen prior to administering insulin. LPN #24 reported he should have primed two units of insulin before injecting insulin. Interview on 04/11/23 at 10:05 A.M., with Pharmacist #60 said the manufacturer instructions for Humalog insulin Kwik Pen revealed prior to administration of insulin, the insulin pen should be dialed to two units to prime prior to administering insulin to residents. Review of the manufacturer instructions for Humalog Kwik Pen revealed the following: Pull the pen cap straight off Check the liquid in the pen Select a new needle Push the capped needle straight onto the pen and twist the needle on until it is tight Pull off the outer needle shield 365277 Page 2 of 4 365277 04/12/2023 Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013

F 0760 To prime the pen, turn the dose knob to select two units Level of Harm - Minimal harm or potential for actual harm Hold pen with the needle pointing up and tap the cartridge holder gently to collect air bubbles at top Residents Affected - Few Continue holding the pen with needle pointing up and push the dose knob until it stops and zero was seen in the dose window This deficiency represent noncompliance in Complaint Number OH00141400. This deficiency represents continued noncompliance from the complaint survey dated 02/16/23. 365277 Page 3 of 4 365277 04/12/2023 Bradford Place Care Center 1302 Millville Avenue Hamilton, OH 45013

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, staff interview, and policy review, the facility failed to ensure medications were stored securely. This had the potential to affect 13 residents (#30, #35, #36, #37, #40, #42, #43, #44, #46, #49, #52, #54 and #55) who were identified by the facility as independently mobile and/or had confusion out of 40 residents who reside on the unit where the unsecured medications were located. The facility census was 69. Findings include: Observations on 04/11/23 from 6:08 A.M. through 6:28 A.M. revealed Licensed Practical Nurse (LPN) #24 left the medication cart unlocked and unattended when administering medications to Resident #43, #44, and #46. LPN #24 was not in view of the medication cart during medication administration. Interview on 04/11/23 at 6:26 A.M. with LPN #24 revealed he had not locked the medication cart while he entered the resident rooms to administer medications. Review of the facility policy titled General Dose Preparation and Medication Administration, dated 01/01/13 revealed the facility should ensure that medication carts were always locked when out of sight or unattended. This deficiency represents continued noncompliance from the annual survey dated 12/29/22. 365277 Page 4 of 4