Health inspection·May 30, 2024

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, medical record review, staff interview, review of manufacturer instructions, and review of facility policy, the facility failed to ensure medications were administered as ordered by the physician, within prescribed time frames, and in accordance with manufacturer instructions for use, resulting in a medication error rate above five percent (%). A total of four medications errors were observed out of 39 opportunities for a medication administration error rate of 10.26%. This affected one (#1) of three residents observed during medication administration. The facility census was 38. Residents Affected - Few Findings include: Review of Resident #1's physician orders noted the medications and prescribed times as indicated; on 05/19/24, Advair Diskus Aerosol Powder Breath Activated 250-50 micrograms (mcg) per(/) dose (Fluticasone-Salmeterol) one inhale orally every 12 hours related to chronic obstructive pulmonary disease (COPD) with acute exacerbation of shortness of breath with prescribed times 8:00 A.M. and 8:00 P.M.; on 03/08/24, Ipratropium-Albuterol Solution 0.5-2.5 milligrams (mg)/3.0 milliliter (ml) inhale orally every four hours for COPD prescribed times 12:00 A.M., 4:00 A.M., 8:00 A.M., 12:00 P.M., 4:00 P.M., 8:00 P.M.; on 10/17/23, Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Lispro) inject as per sliding scale: if 141 - 180 = two units; 181 - 220 = three units; 221 - 260 = four units; 261 - 300 = five units; 301 - 350 = eight units; 351 - 400 = 10 units; 401 or greater than 400 give, 12 units and call physician, subcutaneously before meals and at bedtime related to Type II Diabetes Mellitus; on 05/22/24, Polyvinyl Alcohol 1.4 % solution administer one drop in each eye three times daily for dry eyes. Observation on 05/30/24 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #400 obtaining medications for Resident #1 from the medication cart outside the resident's room. Medications included the following: Advair Diskus Aerosol Powder Breath Activated 250-50 mcg, Ipratropium-Albuterol Solution 0.5-2.5 mg/3.0 ml Lispro Insulin Pen 100 unit per (/) ml. LPN #400 stated she was unable to find Polyvinyl Alcohol 1.4 % Solution eye drops and would not administer due to unavailable. On 05/30/24 at 9:21 A.M., Dietary Aide (DA) #500 exited Resident #1 room carrying Resident #1's breakfast tray. Observation with LPN #400 noted the resident had consumed 75% of the meal. On 05/30/24 at 9:27 A.M., LPN #400 entered Resident #1's room with the medications. At 9:29 A.M., LPN #400 dialed two units to the indicator window of insulin the Lispro insulin pen. No prime of the pen was initiated. LPN #400 proceeded to administer an injection of the pen to the resident's right lower abdominal quadrant. LPN #400 proceeded to administer the Advair Diskus Aerosol. At 9:32 A.M., LPN #400 placed the contents of Ipratropium-Albuterol Solution into an aerosol machine chamber and placed the aerosol mask connected to the chamber on the resident. Page 1 of 3 365571 365571 05/30/2024 Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/29/24 at 9:36 A.M., an interview with LPN #400 during review of the medical record confirmed Resident #1's insulin was to be provided before meals, and the aerosol treatments were administered outside prescribed time frames. LPN #400 indicated she was unaware the Lispro Insulin Pen required priming prior to administration and verified the eye drops were not available in the facility. Review of Humalog KwikPen (insulin lispro) instructions for use revised 07/2023 revealed priming the pen which removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If pen is not primed before each injection, this may result in the patient receiving too much or too little insulin. To prime pen, turn the dose knob to select two units. Hold pen with needle pointing up. Tap cartridge holder gently to collect air bubbles at the top. Continue holding pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. Insulin should be seen at tip of needle. If insulin is not seen, repeat priming no more than four times. If still no insulin is observed, change the needle and repeat priming. According to facility's Medication Administration Procedure, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time, except before or after meal orders, which are administered based on meal times. This deficiency represents non-compliance investigated under Complaint Number OH00153881. 365571 Page 2 of 3 365571 05/30/2024 Otterbein Portage Valley 20311 Pemberville Rd Pemberville, OH 43450

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, review of the manufacturer instructions, and review of the facility policy, the facility failed to ensure a resident was free from a significant medication error when medications were not administered as ordered by the physician. This affected one (#1) of three residents observed during medication administration. The facility census was 38. Residents Affected - Few Findings include: Review of Resident #1's physician orders noted the medications and prescribed times as indicated; Humalog KwikPen Subcutaneous Solution Pen-injector 100 unit per milliliter (ml) (Insulin Lispro) inject as per sliding scale: if 141 - 180 = two units; 181 - 220 = three units; 221 - 260 = four units; 261 - 300 = five units; 301 - 350 = eight units; 351 - 400 = 10 units; 401+ Greater than 400 give 12 units and call physician, subcutaneously before meals and at bedtime related to type II diabetes mellitus. Observation on 05/30/24 at 9:20 A.M. noted Licensed Practical Nurse (LPN) #400 obtaining medications for Resident #1 from the medication cart outside the resident's room. Medications included Lispro Insulin Pen 100 unit per ml. On 05/30/24 at 9:21 A.M., Dietary Aide (DA) #500 exited Resident #1's room carrying Resident #1's breakfast tray. Observation with LPN #400 noted the resident had consumed 75% of the meal. On 05/30/24 at 9:27 A.M., LPN #400 entered Resident #1's room with the medications. At 9:29 A.M., LPN #400 dialed two units to the indicator window of insulin the Lispro insulin pen. No prime of the pen was initiated. LPN #400 proceeded to administer an injection of the pen to the resident's right lower abdominal quadrant. On 05/29/24 at 9:36 A.M., an interview with LPN #400 during review of the medical record confirmed Resident #1's insulin was to be provided before meals, and the aerosol treatments were administered outside prescribed time frames. LPN #400 indicated she was unaware the Lispro Insulin Pen required priming prior to administration. Review of Humalog KwikPen (insulin lispro) instructions for use revised 07/2023 revealed priming the pen which removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If pen is not primed before each injection, this may result in the patient receiving too much or too little insulin. To prime pen, turn the dose knob to select two units. Hold pen with needle pointing up. Tap cartridge holder gently to collect air bubbles at the top. Continue holding pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly. Insulin should be seen at tip of needle. If insulin is not seen, repeat priming no more than four times. If still no insulin is observed, change the needle and repeat priming. According to facility policy titled Medication Administration Procedure, revised 11/09/21, revealed medications are administered in accordance with written orders of the attending physician or physician extender. Medications are administered within one hour before or one hour after scheduled time, except before or after meal orders, which are administered based on meal times. This deficiency represents non-compliance investigated under Complaint Number OH00153881. 365571 Page 3 of 3