Health inspection·August 13, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and facility policy review, the facility failed to administered medications to residents as ordered. The medication administration observation identified four medication errors out of 39 medications administered for a medication error rate of 10.26 percent. This affected three (#19, #26, and #27) of four residents reviewed for medication administration. The facility census was 70. Residents Affected - Few Findings include: 1. Review of medical records for Resident #19 revealed an admission dated 02/04/23. Diagnoses included multiple sclerosis, peripheral vascular disease, age related cataract bilateral, dry eye syndrome of bilateral lacrimal glands, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was assessed as moderately cognitively impaired. Review of a physician order dated 07/25/24 revealed Resident #19 was ordered Refresh Liquigel Ophthalmic Gel one (1) percent (%) eye drops to instill one drop in both eyes two times a day for dry eyes. 2. Review of medical records for Resident #26 revealed an admission date of 07/13/24. Diagnoses included acute kidney failure, heart failure, elevation of levels of liver transaminase levels, and cardiac pacemaker. Review of the MDS assessment dated [DATE] revealed Resident #26 was assessed as cognitively intact. Review of a physician order dated 07/14/24 revealed Resident #26 was ordered the combination medication for treatment of hepatitis C, sofosbuvir and velpatasvir 400-100 milligrams (mg) by mouth once daily. 3. Review of medical records for Resident #27 revealed an admission dated of 10/03/21. Diagnoses included epilepsy, agoraphobia with panic disorder, type two diabetes, schizophrenia, and dementia. Review of the MDS assessment dated [DATE] revealed Resident #27 was assessed as cognitively intact. Review of a physician order dated 08/23/22 revealed Resident #27 was ordered Biotene [NAME] Mouth Page 1 of 2 365690 365690 08/13/2024 Cedarview Care Center 115 Oregonia Road Lebanon, OH 45036

F 0759 Liquid to give two tablespoons by mouth two times a day for dry mouth for swish and spit. Level of Harm - Minimal harm or potential for actual harm Review of a physician order dated 05/23/24 revealed Resident #27 was ordered the antipsychotic medication Zyprexa five (5) mg by mouth one time a day. Residents Affected - Few Observation on 08/13/24 from 9:14 A.M. through 10:14 A.M. with Registered Nurse (RN) #304 revealed the nurse administered medications to Resident #19, Resident #26, and Resident #27. Observations during medication administration revealed Resident #19 did not receive Refresh 1% eye drops, Resident #26 did not receive sofosbuvir and velpatasvir 400-100 mg, and Resident #27 did not receive her Zyprexa 5 mg and Biotene mouth wash for dry mouth as ordered. Interview on 08/13/24 at 11:49 A.M. with RN #304 confirmed Resident #27 did not receive her Zyprexa 5 mg one tablet with the morning medication pass. RN #304 stated he was sure he gave that medication, and RN #304 looked in the medication cart, and verified Zyprexa 10 mg was in the medication cart, not Zyprexa 5 mg. RN #304 verified he signed off in Resident #27's medication administration record (MAR) as the medication was given. RN #304 also verified Resident #27 did not receive Biotene swish and spit medication because the pharmacy had not delivered it yet. RN #304 also verified he did not administer Refresh tears liquid gel eye drops to Resident #19. RN #304 checked in the medication cart and no Refresh liquid gel eye drops were in the medication cart for Resident #19. RN #304 verified that Resident #26 did not receive the sofosbuvir and velpatasvir 400-100 mg tablet because the pharmacy had the medication on back order. Interview on 08/13/24 at 3:08 P.M. with the Director of Nursing (DON) stated he forgot to get clarification for Resident #26's sofosbuvir and velpatasvir 400-100 mg tablet usage in asking the physician to clarify the diagnosis for the medication ordered by the hospital. The DON stated he reached out to Resident #26's primary care provider today to get the physician's name who ordered medication from the hospital. The DON stated Resident #26 was admitted to the facility on [DATE], and did not have her medication, since pharmacy notified him on 07/30/24 in an email that stated the physician did not put the correct diagnosis on the medication when ordered. The DON stated the pharmacy would not pay for medication. Review of the undated facility policy titled, Administering Medication, revealed the medication must be administered in accordance with the orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH00155905. 365690 Page 2 of 2