Health inspection·August 21, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, medical record review, and policy review, the facility failed to ensure residents received medications as ordered. This affected one (#20) of four residents reviewed for medications. The facility census was 79. Findings include: Review of the medical record for Resident #20 revealed an admission date of 04/11/19. Diagnoses included unspecified Alzheimer's disease, pseudobulbar effect, and unspecified anxiety disorder. Review of Resident #20's physician orders revealed an order dated 08/07/22 for the narcotic pain medication oxycodone five (5) milligrams (mg), to give 2.5 mg by mouth twice daily for knee pain. Review of a progress noted dated 06/30/23 revealed Licensed Practical Nurse (LPN) #23 administered oxycodone 5 mg instead of oxycodone 2.5 mg to Resident #20. Interview on 08/21/23 at 1:59 P.M., LPN #23 verified she had made a medication error on 06/30/23 when she gave Resident #20 a double dose of oxycodone by mistake. LPN #23 stated she thought she was administering Resident #20's 5:00 P.M. dose of oxycodone 2.5 mg and 6:00 P.M. dose of the antianxiety medication Ativan 0.5 mg when, in actuality, she removed the medications from two separate medication cards of oxycodone 2.5 mg tablets. LPN #23 stated she did not notice her mistake until a few hours later when she tried to reconcile the narcotics books and noticed the counts were off. Review of policy titled, General Dose Preparation and Medication Administration, dated 12/01/07, revealed the facility staff should verify that the medication name and dose are correct when compared to the medication order of the medication administration record. This deficiency represents non-compliance investigated under Complaint Number OH00145219. Page 1 of 2 365777 365777 08/21/2023 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure that medications were stored properly in medication carts. This affect one (#65) of eleven residents on the D-Hall with active prescriptions for the pain medication Tylenol 500 milligram (mg) tablets. The facility census was 79. Findings include: Review of the medical record revealed Resident #65 admitted to the facility on [DATE] and had primary diagnosis of unspecified rheumatoid arthritis. Review of Resident #65's medical record revealed a physician order dated 01/18/23 for the pain medication acetaminophen (Tylenol) 500 mg, one tablet by mouth three times daily for pain. Observation on 08/21/2023 from 8:48 A.M. to 8:51 A.M. revealed, in the top drawer of the D-Hall medication cart, a large plastic drinking cup labeled Tyle 500 with marker on the outside of the cup. Observed inside the cup was an unspecified, but numerous, quantity of round white tablets, and the tablets were marked with M2A4 57344. Licensed Practical Nurse (LPN) #136 administered four medications to Resident #65 including the antidepressant Cymbalta 60 mg, the stool softener Miralax 17 grams, the diuretic Aldactone 25 mg, and Tylenol 500 mg. LPN #136 took one of the round white tablets from the cup labeled Tyle 500 and administered it to Resident #65. Interview on 08/21/2023 at 8:48 A.M., LPN#136 stated she was aware medications were not supposed to be stored the way the round white tablets were stored during the observation on 08/21/23, and stated she did not put the Tylenol in the medication cart like that. LPN #136 stated the medication was already stored in the medication cart that way when she came on shift, and verified she did not normally work on that medication cart. Interview on 08/21/2023 at 9:19 A.M., the Director of Nursing (DON) stated she was not aware nurses were storing medications inappropriately in the medication carts. The DON stated central supply ordered Tylenol in large bottles that did not fit in the top drawer of the medication carts, but would start to order smaller bottles. Review of a policy titled, Storage and Expiration Dating of Medications and Biologicals, dated January 2022, revealed the facility should ensure that the medications and biologicals are stored in the containers in which they were originally received. 365777 Page 2 of 2