Health inspection·December 5, 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, review of hospital discharge orders, staff interview and review of medication information from Medscape, the facility failed to ensure a resident received anticoagulant medications as physician ordered resulting in significant medication errors. This affected one (#10) of three residents reviewed for medication administration. Facility census was 65. Residents Affected - Few Findings include: Review of medical record for Resident #10 revealed admission date of 10/30/23. Diagnoses include atherosclerosis of native arteries of extremities with intermittent claudication in bilateral legs, peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Resident #10 was discharged on 11/02/23 to the emergency room, and then discharged home. Review of Resident #10's five-day Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. He was independent for eating, bed mobility, clean up assistance for toileting, partial to moderate assistance for transfers. Review of the hospital admitting orders revealed an order for Enoxaparin Sodium (anticoagulant) inject 0.7 milliliters (ml) under the skin every 12 hours. Warfarin (anticoagulant) five mg tablet, take one and a half tablets on Monday, Wednesday and Friday. Warfarin five mg tablet, take one tablet on Sunday, Tuesday, Thursday and Saturday. Review of the physician orders revealed no order for Enoxaparin. An order with a start date of 11/01/23 for Warfarin five mg one and half tablets every Monday, Wednesday and Friday. An order 11/02/23 on for Warfarin five mg in the evening of Tuesday, Thursday, Saturday and Sunday. Review of the November 2023 Medication Administration Record (MAR) revealed no documentation Warfarin had been given. Additionally, there was no documentation regarding the administration of Enoxaparin. Interview on 12/05/23 at 1:51 P.M. with the Director of Nursing (DON) revealed it was reported to her Resident #10 had been upset with staff regarding his medications. The DON stated upon review it was discovered Resident #10's medications had not been ordered properly upon his admission. The DON verified Resident #10's admission medications were not initiated upon as prescribed, and he did not receive Enoxaparin Sodium or Warfarin as ordered. Review of medication information from Medscape (at Page 1 of 2 365426 365426 12/05/2023 Arbors West 375 West Main Street West Jefferson, OH 43162

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few https://reference.medscape.com/drug/lovenox-enoxaparin-342174 and https://reference.medscape.com/drug/coumadin-jantoven-warfarin-342182) revealed Enoxaparin (Leovenox) is an injectable anticoagulant and can be used to treat or prevent deep vein thrombosis, unstable angina (chest paint) or acute coronary syndrome. Warfarin (Coumadin) is an oral anticoagulant and can be used to treat conditions such as venous thrombosis, stroke, cardiac valve replacement, post-myocardial infarction. According the Medscape anticoagulants should not be increased or stopped unless directed by a doctor. This deficiency represents non-compliance investigated under Complaint Number OH00148132. 365426 Page 2 of 2