Health inspection·September 12, 2024

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the facility policy, and staff interview, the facility failed to ensure physician ordered laboratory services for a resident were completed in a timely manner. This affected one (Resident #10) of three residents reviewed for laboratory services. The facility census was 88. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 10/20/22 with diagnoses including Alzheimer's disease, diabetes Mellitus (DM) and dementia. Review of the Minimum Data Set (MDS) assessment completed 07/18/24 revealed Resident #10 had a memory problem and had a diagnosis of DM. Review of Resident #10's physician orders dated 07/18/24 revealed hemoglobin A1C (HbA1c) (a blood test that measures average blood sugar levels over the past two to three months) and basal metabolic panel (BMP) (checks the body's fluid balance and levels of electrolytes) every six months on the second Wednesday in August and January due to a diagnosis of DM. Review of the physician notes dated 07/18/24 revealed a new order received from certified nurse practitioner for BMP and HbA1c every six months starting in August. The physician note completed 08/09/24 revealed the labs were not completed that were ordered on last visit, will re-order today. Review of the medication administration record (MAR) for Resident #10 revealed a BMP, Complete Blood Count (CBC), and Thyroid Stimulating Hormone (TSH) were ordered and completed on 08/12/24. However, review of laboratory results revealed there were were no labs drawn on 08/12/24 and the BMP and HbA1C was never drawn from 07/18/24 to 09/11/24. Interview on 09/12/24 at 10:02 AM with the Administrator and Director of Nursing (DON) confirmed Resident #10's physician orders for BMP and HbA1C to be drawn on 07/18/24 and 08/09/24 but were never drawn from 07/18/24 to 09/11/24. The Administrator and DON confirmed the CBC and TSH labs were not completed too. The Administrator and DON stated the laboratory company was not sent out to obtain Resident #10's labs. Review of the facilities Physician Orders policy dated 06/09/22 revealed the nurse that takes the physician order will be responsible for executing the order. The nurse should contact laboratory services to execute the order. This was an incidental finding discovered during the course of the complaint investigation. Page 1 of 2 365717 365717 09/12/2024 The Convalarium of Dublin 6430 Post Rd Dublin, OH 43016

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of the facility policy, and staff interview, the facility failed to complete hand hygiene during medication administration to residents in enhanced barrier precautions. This affected two (Resident #24 and #70) of four residents observed for medication administration. The facility census was 88. Residents Affected - Few Findings include: Observation on 09/12/24 at 12:07 P.M. with Licensed Practical Nurse (LPN) #999 revealed prior to preparing medication for Resident #70, hand hygiene was not performed, and gloves were not worn. LPN #999 began preparing Resident #70's medication, directly from the medication card into the medication cup. LPN #999 then returned the medication card to the cart, locked it, and entered Resident #70's room, which had an enhanced barrier sign posted on the door. Resident #70 needed moderate assistance with medication administration, including spoon-feeding the medication with applesauce. Resident #70 took medications without difficulty. Upon exiting, hand hygiene was not performed by LPN #999. Observation on 09/12/24 at 12:15 P.M. with LPN #999 revealed after administering Resident #70's medication, hand hygiene was not performed. LPN #999 unlocked the medication cart and started preparing medications for Resident #24. LPN #999 poured Tylenol from a shared facility bottle into the medication cup and then retrieved a medication card from the medication cart and popped it into the cup. LPN #999 returned the medication card to the cart, locked it, and entered Resident #24's room, which had an enhanced barrier precautions sign posted on the door. LPN #999 gave Resident #24 his medication, which he took without issues. After completing the task, LPN #999 discarded the medication cup in the trash, exited the room without performing hand hygiene, and returned to the medication cart. Interview on 09/12/24 at 12:20 P.M. with LPN #999 confirmed that hand hygiene was not performed as required before and after preparing Resident #70 and #24's medications. Review of the Enhanced Barrier Precautions signage from United States Department of Health and Human Services, undated, revealed everyone must clean their hands, including before entering and when leaving the room. Review of the facilities Infection Control- Isolation/Precautions policy dated 08/2024 revealed staff must perform hand hygiene before and after contact with the resident and after contact with blood, body fluids, visibly contaminated surfaces or after contact with objects in the resident's room. This was an incidental finding discovered during the course of the complaint investigation. 365717 Page 2 of 2