Health inspection·April 18, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, facility protocol review, and hospital record review, the facility failed to ensure residents received treatment and care in accordance with professional standards when they failed to hold blood pressure medications and notify the doctor of a low blood pressure for Resident #77. This resulted in actual harm when Resident #77 was hospitalized with diagnoses of hypotension, acute kidney injury, and altered mental status. Resident #77 had an elevated Blood Urea Nitrogen (BUN) level of 110 milligrams per deciliter (mg/dl), and elevated creatinine level of 3.22 mg/dl, and a hospital emergency room triage blood pressure of 80/36 millimeters of mercury (mmHg). This affected one (Resident #77) of three residents reviewed for hospitalization. The facility census was 79. Residents Affected - Few Findings include: Record review of Resident #77 revealed an admission date of 03/02/24 with an admission to the hospital on [DATE] and a readmission to the facility on [DATE]. Resident #77 had pertinent diagnoses including wedge compression fracture of fifth lumbar vertebrae, low back pain, pain in right hip, unilateral primary osteoarthritis right hip, chronic peripheral venous insufficiency, dementia without behavioral disturbances, muscle weakness, gait and mobility abnormalities, opioid dependence, atrial fibrillation, depression, hyperlipidemia, irritable bowel syndrome, fibromyalgia, hypertension, anxiety disorder, and migraine. Review of the 03/05/24 Medicare five-day Minimum Data Set (MDS) assessment revealed Resident #77 was moderately cognitively impaired and used a manual wheelchair to aid in mobility. Resident #77 required setup or clean up assistance for eating, and oral hygiene. She was dependent for toileting, showering, lower body dressing, and putting on taking off footwear. Resident #77 required partial/moderate assistance for roll left and right, sit to lying, lying to sitting, and sit to stand. Review of a hospital record dated 02/24/24 revealed Resident #77's BUN level (a test used to test kidney function) was 32 mg/dl (normal range is 3-29 mg/dl). The creatinine (a test used to test kidney function) was 3.22 mg/dl (normal is 0.5-1.2). Review of a Physician Order dated 03/02/24 revealed Metoprolol Tartrate Oral Tablet give 12.5 milligrams (mg) by mouth one time a day for hypertension. Review of a Physician Order dated 03/02/24 revealed an order for Losartan Potassium Oral Tablet 50 mg, give one tablet by mouth one time a day for hypertension. Review of a Physician Order dated 03/02/24 revealed Propranolol HCl Oral Tablet 10 mg, give one tablet by mouth at bedtime for hypertension. Page 1 of 4 365777 365777 04/18/2024 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0684 Review of a Physician Order dated 03/03/24 revealed Diovan/Hydrochlorothiazide (HCL) Oral Tablet 160/25 mg give one tablet by mouth one time a day for hypertension. Level of Harm - Actual harm Review of vital signs revealed on 03/04/24 at 4:45 A.M., Resident #77's blood pressure was 131/72 mmHg. Residents Affected - Few Review of vital signs revealed on 03/04/24 at 7:43 A.M. her blood pressure was 98/43 mmHg. The medication administration record revealed her blood pressure medications were given that morning on 03/04/24. The doctor was not notified of the low blood pressure and the medications were not withheld. Review of the vital signs revealed on 03/04/24 at 9:32 P.M. her blood pressure was 88/32 mmHg. Resident #77's propranolol was held by the nurse due to low blood pressure and she did not notify the doctor. The medical record had no mention of notifying the physician. Review of vital signs revealed on 03/05/24 at 9:51 A.M. her blood pressure was 104/67 mmHg. Resident #77's blood pressure medications were given that morning. Review of nurses' notes dated 03/05/24 at 1:58 P.M. revealed Resident #77's daughter requested her mother be sent out to hospital stating, she is not where she was mentally prior to hospitalization, and she is hallucinating. Orders were received from Medical Director #100 to send to the emergency room for evaluation. Transport picked her up at 1:30 P.M. Review of hospital records dated 03/05/24 revealed a hospital emergency room triage blood pressure of 80/36 mmHg at 1:43 P.M. with admitting diagnoses of hypotension, acute kidney injury, and altered mental status with an elevated BUN level of 110 mg/dl, elevated creatinine level of 3.22 and Resident #77 was hospitalized for nine days and returned to the facility on [DATE]. Interview with Registered Nurse (RN) #15 on 04/11/24 at 10:40 A.M. revealed on 03/05/24 she called Medical Director #100 to send Resident #77 out. Resident #77 was answering questions appropriately; however, the family wanted her to be sent out to the hospital. RN #15 was not sure if she called the Physician for Resident #77's blood pressure on 03/04/23 and she stated she did give her blood pressure medications on 03/04/24 and 03/05/24. Interview with the Medical Director #100 on 04/11/24 at 11:40 A.M. revealed Resident #77 was in the assisted living part of the facility and went to the hospital and came back skilled in the Nursing Home. The Medical Director verified she was not notified of the blood pressure of 98/43 mmHg on 03/04/24 at 7:43 A.M. or of the blood pressure of 88/32 mmHg on 03/04/24 at 9:32 P.M. Medical Director #100 stated she would have held all blood pressure medications, drew labs, gave midodrine medication to bring up the blood pressure, encouraged oral fluids if able, or started intravenous fluids. She stated they have a protocol sheet here that addresses medical concerns including hypotension for nurses to follow. The Medical Director #100 was asked if it is normal for someone to have an acute kidney injury after a few days of being admitted and she stated sometimes residents do not eat or drink adequately when they come into the nursing home. Review of fluid intakes on 04/11/24 revealed on 03/03/24 Resident #77 was documented as taking in 480 milliliters of fluid, 03/03/24 is blank for fluid intake, and 03/04/24 documented 720 milliliters of fluid intake. Review of an undated facility Protocol Order Set: Hypotension on 04/11/24 revealed the protocol is 365777 Page 2 of 4 365777 04/18/2024 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0684 to be utilized by the RN/LPN and delegated as appropriate within the scope and practice. Level of Harm - Actual harm Assessment: Systolic blood pressure (SBP) <100 mmHg Residents Affected - Few Plan: 1. Implementation: • Hold all blood pressure medications for systolic blood pressure (SBP) <100 • If not on blood pressure medications and SBP consistently <100, begin: Proamatine (midodrine) 5 milligrams (mg) by mouth, twice a day: scheduled at 8:00 A.M. and 2:00 P.M. • If not taking in orally, obtain complete blood count (lab test that test blood levels) and basic metabolic panel (lab test that tests electrolytes and other tests) 2. Nursing Action: • Assess the amount of oral intake in the last 24 hours. • Assess ability to tolerate oral intake. • Assess the frequency/volume urination in the last 24 hours. 3. Criteria for calling the Physician/Advanced Practice Provider: • Systolic blood pressures <90 mmHg 4. Follow Up: • Repeat blood pressure prior to the next dose of medication. • 365777 Page 3 of 4 365777 04/18/2024 Trinity Community 3218 Indian Ripple Road Beavercreek, OH 45440

F 0684 Monitor vitals and report for improvement or persistent worsening symptoms. Level of Harm - Actual harm • Residents Affected - Few Notify DPOA/responsible party. • Document in progress notes. This deficiency represents non-compliance investigated under Complaint Number OH00152332. 365777 Page 4 of 4