Health inspection·October 3, 2019

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, staff interview and facility policy review ,the facility failed to monitor laboratory tests in accordance with physician orders to ensure the adequate use of medications for one resident (#44) of five reviewed for unnecessary medications. The faciltiy census was 60. Residents Affected - Few Findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), epilepsy, diabetes mellitus type II, major depressive disorder severe recurrent with psychotic symptoms, chronic obstructive pulmonary disease, and hypertension. Review of Resident #44's current physician orders revealed the resident was ordered Glucotrol 5 milligrams (mg) twice a day, 15 units of Basaglar insulin twice a day, and Trulicity injection of 0.5 milliliter (0.75 mg) every Tuesday. The resident was also ordered to have laboratory tests every three months which consisted of a complete blood count (CBC-to evaluate overall health), comprehensive metabolic panel (CMP- body's fluid balance), and a Hemoglobin A1c (HBA1c-average of blood glucose levels). Review of Resident #44's medical record revealed the last lab tests completed were 03/01/19 and 09/06/19. There was no evidence the labs had been drawn in June 2019 as ordered. Interview with the Director of Nursing (DON) on 10/02/19 at 2:19 P.M. verified labs ordered for Resident #44 had not been done in June 2019. Review of a facility policy titled Lab and Diagnostic Test Results-Clinical Protocol with a revision date of November 2018 revealed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring need. The staff will process test requisitions and arrange for tests. Page 1 of 2 365483 365483 10/03/2019 Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to have hospice progress notes available for review. This affected one (#26) of one resident reviewed for hospice services. The facility census was 60. Findings include: Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, atherosclerotic heart disease, psychosis, hypertension, malignant neoplasm of breast (cancer), and Alzheimer's disease. The resident was admitted to Hospice services on 05/17/19 with an end stage diagnosis of Alzheimer's disease. Interview on 10/01/19 at 1:08 P.M. with the Unit Licensed Practical Nurse (LPN) #219 revealed the Hospice nurse visits Resident #23 one to two times per week. There was no evidences of any hospice notes in the resident's medical record. Review of the Hospice binder on the unit revealed a comprehensive assessment and hospice care plan dated 05/19/19 were the only notes for Resident #23. Interview on 10/05/19 at 11:45 A.M. with the Director of Nursing (DON) verified there were no Hospice progress notes available in the facility for Resident #23. Review of the facility Hospice agreement dated 05/17/19 revealed the facility and hospice will prepare and maintain complete medical records for hospice patients receiving facility services in accordance with this agreement and will include all treatments, progress notes, authorizations, physician orders and other pertinent information. Documentation of care and services provided by hospice will be filed and maintained in the facility chart. 365483 Page 2 of 2