Health inspection·February 6, 2020

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and manufacturer's guideline review the facility failed to ensure residents were free from significant medication errors when the insulin pen was not primed prior to use according to manufacturer's guidelines. This may cause the resident to get too much or too little insulin. This affected one resident (#139) of one resident observed for insulin administration. Facility census was 87. Residents Affected - Few Findings include Review of the medical record revealed Resident #139 was admitted to the facility on [DATE]. Diagnoses included diabetes, osteomyelitis of the vertebra, sacral, and sacrococcygeal region. Review of the physician order dated 12/09/19 revealed the Resident #139 had orders for ADMELOG Solostar (Insulin Lispro) before meals and at bedtime based on the resident's blood glucose level, as follows: -0 milligrams/deciliter (mg/dl) to 150 mg/dl, no insulin was administered -151 mg/dl to 200 mg/dl, four units of insulin was administered -201 mg/dl to 250 mg/dl, six units of insulin was administered -251 mg/dl to 300 mg/dl, eight units of insulin was administered -300 mg/dl to 350 mg/dl, ten units of insulin was administered -351 mg/dl to 400 mg/dl, 12 units of insulin was administered -greater than 400 mg/dl, call the physician for further orders Review of the comprehensive assessment dated [DATE] revealed the resident had intact cognition. Observation on 02/05/20 at 11:00 A.M. revealed Licensed Practical Nurse (LPN) #200 obtained a blood sugar reading of 357 mg/dl for Resident #139, which required 12 units of insulin to be administered. LPN #200 cleaned the Lispro Kwikpen, attached the needle, and primed the needle with two units of insulin. The LPN then removed the needle from the pen, attached a different needle, and selected and administered 12 units of insulin to Resident #139. Page 1 of 3 365799 365799 02/06/2020 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/05/20 at 11:00 A.M. with LPN #200 revealed the needle had retracted and the LPN was not able to select the dose of insulin to administer. The LPN did not think the new needle needed to be primed and proceeded to administer the injection. The LPN verified the second needle placed on the insulin pen was not primed. Review of the manufacturer instructions for use of the Lispro KwikPen revealed if the needle was not primed prior to each injection too much or too little insulin may be injected. Instructions to prime the needle included attaching the needle to the pen, turning the dose knob to select two units, and pushing the dose knob in until it stopped and a 0 was seen in the the dose window. 365799 Page 2 of 3 365799 02/06/2020 West Park Care Center LLC 1700 Heinzerling Drive Columbus, OH 43223

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 record review, observation, resident interview, staff interview, and policy review the facility failed to ensure a resident's medications were consumed prior to exiting the room. This affected one Resident (#13) of 18 residents reviewed. The facility census was 87. Findings include: Review of the medical record revealed Resident #13 admitted to the facility 10/04/19. Diagnoses included heart disease, hypertension, hyperlipidemia and osteoarthritis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had intact cognition and required limited assistance from staff with activities of daily living. Observation on 02/03/20 at 10:17 A.M. revealed three white pills in a small clear cup on Resident #13's bedside table. Observation and Interview on 02/03/20 at 10:18 A.M. with the Licensed Practical Nurse (LPN) #209 and Resident #13 confirmed there were three white pills in a small clear cup on Resident #13's bedside table. Resident #13 stated she was unable to swallow her last three pills. LPN #209 confirmed she had passed Resident #13's ordered medication prior this morning. She stated she had been in Resident #13's room for 10 minutes because she was swallowing her pills one at a time and it was taking a long time. LPN #209 stated she observed Resident #13 take a sip of water and thought that she had swallowed her remaining three pills. Resident #13 stated she had put the last three pills in her mouth at the same time, however was unable to swallow them and she spit them into her clear cup. LPN #209 stated it was policy to ensure residents swallowed their medications to ensure they received their ordered medications and no medications were supposed to be left unattended in a residents room. She confirmed she did not ensure Resident #13 had swallowed her medications. LPN #209 stated she thought one of the medications was aspirin but was unable to identify the two other white pills as the coating had been compromised from being in Resident #13's moist mouth. Review of a facility policy titled, Medication Storage, undated, revealed medications were to be stored in a safe and secure manner and in compliance with corresponding regulations and manufacturers guidelines. Review of a facility policy titled, Medication Administration, undated, revealed medication was to be administered in a safe manner that met all regulatory guidelines. 365799 Page 3 of 3