Health inspection·December 18, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected #81 of three residents reviewed. The census was 78. Findings include: Review of Resident #59's medical record revealed an admission date of 09/19/23. Diagnoses included end stage renal disease, hypertensive heart failure, hemiplegia, type two diabetes mellitus, and chronic leg ulcer. Review of a quarterly Minimum data Set (MDS) assessment dated [DATE] revealed Resident #59 was severely cognitively impaired. Review of physician orders revealed an order dated 11/02/23 for Percocet (narcotic pain medication oxycodone and acetaminophen) five and 325 milligrams (5-325 mg) give 5-325 every four hour as needed (PRN) for pain. Give every four hours PRN for general discomfort repositioning, relaxation, distraction and comfort measures provided and ineffective. Review of the facility's Controlled Drug Record revealed one tablet of Percocet 5-325 mg was documented as being withdrawn on 12/14/23 at 10:00 A.M. and on 12/14/23 at 4:00 P.M. Review of medication administration records (MAR's) revealed no documentation of Percocet 5-325 mg being administered on 12/14/23 at 10:00 A.M. and on 12/14/23 at 4:00 P.M. During a phone interview on 12/18/23 at 10:00 Registered Nurse (RN) #200 stated she administered Percocet 5-325 mg to Resident #59 on 12/14/23 at 10:00 A.M. and on 12/14/23 at 4:00 P.M. RN #200 was unable to explain why the Percocet administrations were not documented in Resident #59's MAR. During an interview on 12/18/23 at 11:07 A.M. A.M. the Director of Nursing (DON) confirmed the missing and inaccurate documentation in Resident #59's MAR for Percocet 5-325 mg. Review of the facility's policy titled Medication Administration-General Guidelines dated November 2021 revealed the individual who administers the medication dose records the administration on the resident's medication administration record (MAR) and or electronic medication administration record (eMar) directly after the medication is given. At the end of each medication pass the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and Page 1 of 2 365640 365640 12/18/2023 Sycamore Trails Post Acute 450 Oak Ridge Boulevard Miamisburg, OH 45342

F 0842 Level of Harm - Minimal harm or potential for actual harm documented. In no case should the individual who administers the medications report off-duty without first recording the administration of medications. This deficiency represents non-compliance investigated under Complaint Number OH00148990. Residents Affected - Few 365640 Page 2 of 2