Health inspection·September 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, staff interview, medical record review, and policy review, the facility failed to ensure a medication error rate of less than five percent (5%). This affected two (#64 and #80) of four residents observed for medication administration. There were 29 opportunities with four medication errors for a medication error rate of 13.7%. The facility census was 98. Residents Affected - Few Findings include: 1. Review of Resident #64's medical record revealed an admission date of 09/19/24, with diagnoses of: anoxic brain damage, muscle weakness, dysphagia, cognitive communication deficit, insomnia, chronic obstructive pulmonary disease, and encounter for attention for gastrostomy. Review of a physician order dated 09/19/24 revealed an order for aspirin low dose 81 milligram (mgs) tablet chewable, give one tablet via percutaneous endoscopic gastrostomy tube (PEG) (a feeding tube that is surgically inserted through the abdominal wall and into the stomach) one time a day and an order for Guaifenesin Extended Release (ER) tablet 12 hour, 600 mgs, give one tablet via PEG tube every 12 hours for cough. Review of a physician order dated 09/22/24 revealed an order for baclofen (muscle relaxer medication) oral tablet 10 mgs give one tablet via PEG tube three times a day for muscle contraction. Observation of a medication administration pass with Certified Medication Aide (CMA) #16 on 09/30/24 at 8:32 A.M., revealed she passed oral medications of baclofen 10 mgs, Guaifenesin 600 mg ER, and aspirin 81 mg enteric coated. CMA #16 crushed all three medications including and put them in pudding and gave them to Resident #64 by mouth. Interview on 09/20/24 at 10:03 A.M., with CMA #16 verified the order says all three medications should be given by PEG tube and she gave them by mouth. She also verified the Guaifenesin 600 mg ER, and aspirin 81 mg enteric coated should not have been crushed since they are extended release and enteric coated. 2. Review of Resident#80's medical record revealed an admission date of 06/21/19, with diagnoses of: vitamin D deficiency, hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, insomnia, edema, and major depressive disorder. Review of the 07/04/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and does not use any devices to aid in mobility. Review of a physicians order dated 02/21/24 revealed an order for Cholecalciferol Oral Capsule Page 1 of 2 365686 365686 09/30/2024 Columbus Healthcare Center 4301 Clime Road North Columbus, OH 43228

F 0759 (Vitamin D) 125 micrograms (5000 units). Give 1 capsule by mouth in the morning. Level of Harm - Minimal harm or potential for actual harm Observation on 09/30/24 at 9:24 A.M., of Licensed Practical Nurse (LPN) #11 revealed she was passing medications to Resident #80. LPN #11 pulled Cholecalciferol Oral Capsule (Vitamin D) 1250 micrograms (50,000 units). LPN #11 verified she was going to give 50,000 units of Vitamin D. The surveyor intervened and had LPN #11 recheck the order. Residents Affected - Few Interview on 09/30/24 at 9:29 A.M., with Licensed Practical Nurse (LPN) #11 verified she was going to give 50,000 units of Vitamin D instead of the ordered 5,000 units. Review of the undated policy titled; Medication Administration Policy revealed to observe the five rights in giving each medication: the right route. Follow manufacturers recommendations for medications that note do not crush. This deficiency represents non-compliance investigated under Complaint Number OH00157909. 365686 Page 2 of 2