Health inspection·October 12, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to maintain a medication error rate of less than five percent (%). Two errors were observed in 27 opportunities resulting in a 7.41% medication error rate. This affected one resident (#14) of four residents observed for medication administration. The census was 59. Residents Affected - Few Finding Include: On 10/11/23 at 8:02 A.M. Licensed Practical Nurse (LPN) #238 was observed administering medications to Resident #14. The LPN prepared multiple medications for the resident, including Novolog (short acting) insulin pen and Toujeo Solo Star (long acting) pen. LPN #238 prepared the Novolog pen by removing the cap of the and wiping the top of the pen with alcohol and applying the needle. She dialed the dosage to 14. LPN #238 prepared the Toujeo pen by removing the cap of the pen, wiping the top of the pen with alcohol, applying the needle and then dialed the dosage to 30 units. The LPN did not prime the pens. LPN #238 administered Resident 14's whole pills and injected the Novolog and Toujeo insulin injections into the resident's left arm. Interview on 10/11/23 at 08:11 A.M. with LPN #238 revealed her process for administering insulin via a pen was to remove the cap and wipe the top of the pen with alcohol, then apply the needle and dial the dosage. The LPN verified she did not prime the pen to remove all of the air and to ensure the resident was administered the correct dose of insulin as ordered. Review of the resident's physician orders for October 2023 revealed two insulin orders, Novolog (pen) 14 units with meals and Toujeo Solo Star (pen) 30 units one time a day. Review of the manufacturer's instruction for the Novolog pen revealed to prime the pen prior to each injection. Priming the pen meant removing the air from the needle and cartridge that may collect during normal use and ensure the pen was working properly. Review of the manufacturer's instruction for the Toujeo Solo Star pen revealed to always do a safety check to ensure pen and needle were working properly. Select three units by dialing the dose selector and press the injection button. If insulin comes out of the needle tip the pen was properly working. Review of the facility policy titled Insulin Administration, revised September 2014, revealed the nursing staff would have access to specific instructions (manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. Page 1 of 2 365428 365428 10/12/2023 Sanctuary Wadsworth 365 Johnson Rd Wadsworth, OH 44281

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 review of the manufacture storage instructions revealed the facility failed to ensure medication storage guidelines were followed. This affected one Resident (Resident #29) of six residents that received insulin on the 300 unit and had the potential to affect 11 newly admitted residents (Resident #8, #11, #16, #55, #59, #117, #212, #213, #214, #215, #216) requiring Tuberculosis skin testing. The census was 59. Findings Include: 1. Observation on 10/10/23 at 4:54 P.M. of the 300-medication cart with Licensed Practical Nurse (LPN) #261 revealed Resident #29's basaglar kwick pen (long acting) insulin had an expiration date of 12/01/24. The pen had an open date of 09/09/23 that indicated the insulin was open for 32 days, exceeding the recommended 28 days. Interview on 10/10/23 at 4:55 P.M. with LPN #261 verified Resident #29's pen had an opened date of 09/09/23 and had been opened over the recommended 28 day use by date. Review of the facility policy titled Storage of Medication, dated November 2020, revealed discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the manufacturer's instructions for the basaglar kwick pen, dated December 2015, revealed the pen should be thrown away after 28 days, even if it still has insulin left. 2. Observation on 10/10/23 at 5:00 P.M. of the medication room with LPN #261, revealed in the refrigerator was an opened (in use) vial of Tubersol (tuberculin purified protein derivative indicated to aid diagnosis of tuberculosis infection in persons at increased risk of developing active disease) with an expiration date of January 2026. The vial had no open date marked to indicate the recommended 30 day use by date. Review of pharmacy shipping manifest dated 08/03/23 revealed the facility received five Tubersol vials on 08/03/23. Review of the admission list dated 09/03/23 (31 days after the Tubersol was received) through 10/10/23 revealed there were 11 residents (Resident #8, #11, #16, #55, #59, #117, #212, #213, #214, #215, #216) admitted from 09/03/23 through 10/10/23. Interview on 10/10/23 at 5:14 P.M. with LPN #224 verified the finding and stated the vial should have been dated when opened. Review of the manufacturer instructions dated 01/15/23 revealed a vial of Tubersol which has been entered and in use for 30 days should be discarded. 365428 Page 2 of 2