Health inspection·September 4, 2024

F 0760 Ensure that residents are free from significant medication errors. 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 and staff and pharmacist interviews, the facility failed to ensure antibiotics were provided as physician ordered resulting in a significant medication error. This affected one (#12) of three residents reviewed for medication administration. Facility census was 78 Residents Affected - Few Findings include: Review of medical record for Resident #12 revealed an admission date of 03/22/24. Diagnoses include bipolar, anxiety, hypertension and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. Resident #12 required supervision for bed mobility, transfers, toileting and eating. Review of physician records for Resident #12 revealed an order for Imipenem-Cilastatin (antibiotic) intravenous solution reconstituted 500 milligrams (mg)-give intramuscularly four times daily with a start date of 09/02/24. Review of the September 2024 Medication Administration Record (MAR) for Resident #12 revealed Imipenem-Cilastatin (antibiotic) was scheduled four times a day at midnight, 6:00 A.M., 12:00 P.M. and 6:00 P.M. starting on 09/02/24. Further review revealed OT was documented on 09/02/24 at midnight through 6:00 A.M. (with the exception of 09/02/24 6:00 P.M. which was blank). Review of the chart code revealed OT was other. Review of the progress note dated 09/04/24 at 5:40 A.M. revealed Imipenem-Cilastatin was awaiting delivery from the pharmacy. Interview on 09/04/24 at 2:02 P.M. with Registered Nurse (RN) #104 revealed she discovered on 09/03/24 that Resident #12's Imipenem-Cilastatin had not been received from the pharmacy and called them to inquire of the status. RN #104 shared the pharmacy informed her the prescription had been profiled at the pharmacy but the order was not filled/sent out, and she was awaiting further clarification. RN #104 verified the medication had not been given as ordered and clarification had not been received at the time of the interview. Interview on 09/04/24 at 2:20 P.M. with Pharmacist #105 revealed the route Resident #12's Imipenem-Cilastatin was ordered was no longer available. The medication could be given intravenously. Pharmacist 3105 further shared Resident #12 had a previous order for the same medication ordered intravenously which had been filled prior to her recent hospitalization. The readmission orders contained the Page 1 of 2 365640 365640 09/04/2024 Sycamore Trails Post Acute 450 Oak Ridge Boulevard Miamisburg, OH 45342

F 0760 Level of Harm - Minimal harm or potential for actual harm same medication, ordered intramuscularly and the system deemed the most recent prescription as a duplicate order so the prescription was profiled (kept on file). This deficiency represents non-compliance investigated under Complaint Number OH00157637. Residents Affected - Few 365640 Page 2 of 2