Health inspection·May 1, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident interview, and staff interview, the facility failed to residents were free from significant medication errors. This affected two (Resident #23 and Resident #34) out of three residents reviewed for medications. The facility census was 72. Residents Affected - Few Findings include: Review of the medical record for Resident #23 revealed admission date of 02/16/23 with diagnoses including but not limited to malignant neoplasm of rectum, chronic kidney disease stage two, congestive heart failure, and celiac disease. Review of the Minimum Data Set (MDS) assessment, dated 04/22/24, revealed Resident #23 was cognitively intact. Review of Resident #23's physician orders revealed an order for capecitabine (medication used to treat cancer) 500 milligrams (mg) by mouth, give three tablets one time a day seven days on and seven days off for cancer treatment, and give two tablets by mouth at bedtime seven days on and seven days off for cancer treatment. The order had a start date of 02/24/24. Review of Resident #23's Medication Administration Record (MAR) for March 2024 revealed capecitabine 500 mg was documented as not available on 03/28/24 evening shift and 03/29/24 evening shift. Review of the nurse's note, dated 03/29/24, revealed the nurse spoke with the pharmacy about Resident #23's capecitabine. The pharmacy stated the medication will be out on the next run. The nurse stressed the importance of the medication. The pharmacy stated he would have to wait until after 7:00 A.M. to request a refill when the pharmacist comes in but he would call with any questions. Review of Resident #23's nurse's notes revealed there were no nurses notes regarding notification of the physician that the capecitabine was unavailable. Interview with Resident #23 on 05/01/24 at 11:36 A.M. revealed the facility ran out of her medication on one occasion. Interview on 05/01/24 at 2:49 P.M. with Registered Nurse (RN) #705 verified Resident #23's capecitabine was documented as not available on 03/28/24 evening shift and 03/29/24 evening shift. RN #705 verified there was no documentation the physician was notified. Interview on 05/01/24 at 3:55 P.M. with the Director of Nursing (DON) revealed Resident #23 had a pharmacy supply and home supply of cancer medication and it should not have run out. The DON stated Page 1 of 2 365374 365374 05/01/2024 Beavercreek Post Acute 1974 North Fairfield Road Dayton, OH 45432

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was unsure why the nurse documented that the medication was not given on the evening shift when Resident #23 received the day shift dose both days. The DON verified the medication was marked as not available and was not given. 2. Review of the medical record for Resident #34 revealed an admission date of 04/22/13 with diagnoses including but not limited to paraplegia, type two diabetes, major depressive disorder, anxiety, chronic pain disorder, spinal stenosis, and constipation. Review of Resident #34's MDS assessment, dated 01/31/24, revealed the resident was independent for daily decision making. Review of Resident #34's physician orders revealed an order for fentanyl (narcotic pain medication) 75 micrograms patch every 72 hours. The order had a start date of 03/06/24 and a discontinue date of 03/20/24. Review of Resident #34's MAR for March 2024 revealed the fentanyl patch was marked as not available on 03/18/24. Further review of the MAR for March 2024 revealed the fentanyl patch was applied on 03/20/24 when it was received from the pharmacy and the next patch was to be applied on 03/23/24. Review of Resident #34's progress notes revealed no documentation that the physician was notified of Resident #34's fentanyl not being available. Interview on 05/01/24 at 12:55 P.M. with Resident #34 revealed he did not receive his fentanyl patch on 03/18/24 and 03/19/24. Resident #34 stated he received his fentanyl patch on 03/20/24. Interview on 05/01/24 at 2:49 P.M. with RN #705 verified Resident #34's fentanyl was documented as not given. RN #705 stated Resident #34 would try and order medications from another pharmacy and the facility would be unable to reorder the medications. RN #705 verified there was no documentation regarding the physician having been notified of the fentanyl being unavailable or not given. This deficiency represents non-compliance investigated under Complaint Number OH00152754. 365374 Page 2 of 2