Health inspection·March 28, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to ensure a medication error rate of not 5 percent or greater. This affected four (Resident #67, #111, #113 and #131) of six residents observed for medication administration. Five errors were observed out of 35 opportunities resulting in a medication error rate of 14.2%. The census was 111. Residents Affected - Few Findings include: 1. Medical record review revealed Resident #67 was admitted on [DATE] with diagnoses including depression, high blood pressure and pain. Review of the Order Summary dated March 2024 revealed medications to administer included Tylenol Extra Strength 500 milligrams (mg) twice a day for osteoarthritis and Sertraline HCL 50 mg give 1.5 tablet by mouth in the morning for depression. On 03/28/24 at 8:13 A.M., observation of Resident #67's medication administration revealed Licensed Practical Nurse (LPN) #2 administered medications including acetaminophen 500 mg with diphenhydramine 25 mg and Sertraline 50 mg. LPN #2 stated the pharmacy sends Sertraline 25 mg and a Sertraline 50 mg tablet but the resident only gets the 50 mg tablet so she send the Sertraline 25 mg tablet back. 2. Medical record review revealed Resident #111 was admitted on [DATE] with diagnoses including disorder of bone density and structure, hypertension and anxiety. Review of the Order Summary dated March 2024 revealed medications to administer included calcium 600 mg in the morning. On 03/28/24 at 8:31 A.M., observation of Resident #111's medication administration revealed LPN #4 administered Calcium Plus D 600 mg/10 micrograms. 3. Medical record review revealed Resident #113 was admitted on [DATE] with diagnoses including cerebral infarction and osteoarthritis. Review of the Order Summary dated March 2024 revealed medications to administer included a topical 4% lidocaine patch. On 03/28/24 at 8:50 A.M., observation of Resident #113's medication administration revealed LPN #6 entered the resident's room and placed the sealed 4% lidocaine patch on Resident #113's overbed Page 1 of 2 365436 365436 03/28/2024 Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few table. LPN #6 handed Resident #113 the medication cup and took his oral medications. LPN #6 then exited the resident's room leaving the 4% lidocaine patch on the overbed table. LPN #6 verified he had forgot to apply the topical 4% lidocaine patch until the surveyor asked about it. 4. Medical record review revealed Resident #131 was admitted on [DATE] with diagnoses including anxiety, muscle spasms, spinal stenosis and incontinence. Review of the Order Summary dated March 2024 revealed medications to be administered included oxybutynin Chloride ER 10 mg. On 03/28/24 at 9:03 A.M., observation of Resident #131's medication administration revealed LPN #8 did not administer oxybutynin Chloride ER 10 mg as ordered. On 03/28/24 at 11:55 A.M., interview with the Director of Nursing verified medications were to be administered as ordered by the physician. Review of the policy: Medication Errors (dated 03/01/23) revealed it was the policy to provide protections for the health, welfare and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. This deficiency represents non-compliance investigated under Complaint Number OH00151747. 365436 Page 2 of 2