Health inspection·February 8, 2024

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, staff interview, and review of facility policy, the facility failed to administer medications per physician which resulted in a significant medication error for one (#94) of three residents reviewed for medication administration. The facility census was 101. Residents Affected - Few Findings include: Review of the medical record for Resident #94 revealed an admission date of 08/23/23. Diagnosis included pulmonary hypertension (medical condition where the heart and lungs do not pump effectively and can cause significant fluid build up in the pulmonary system, the lungs. This can cause significant difficulty in breathing.) Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact. Review of the physician orders for November 2023, December 2023, and January 2024 revealed Resident #94 was ordered sildenafil 20 milligrams (mg) every six hours for pulmonary hypertension. Review of the care plan, revised 11/27/23, revealed Resident #94 was care planned for pulmonary hypertension with interventions of medication administration per physician orders. Review of the medication administration record (MAR) for December 2023 revealed Resident #94 was not administered the sildenafil 20 mg on 12/13/23, 12/14/23, and the midnight dose on 12/15/23. Review of the nursing progress notes dated from 12/13/23 through 12/15/23 at midnight revealed the sildenafil was not available for administration. Review of the MAR for January 2024 revealed Resident #94 was not administered sildenafil 20 mg as ordered from 01/14/24 the 12:00 P.M. dose through 01/16/24; from 01/17/24 at the 12:00 P.M. through 01/21/24 the 6:00 A.M. dose; from 01/22/24 through 01/23/24, and on 01/25/24 the 12:00 A.M., 6:00 A.M. and the 12:00 P.M. doses. Interview on 02/07/24 at 1:19 P.M. with the Director of Nursing (DON) verified the silidenafil not administered as ordered for Resident #94. Review of the facility policy titled Administration and Documentation of Medications, revised 10/22, revealed nurses are responsible for the proper administration of all medications scheduled during their shifts. Page 1 of 2 365830 365830 02/08/2024 Bryan Healthcare and Rehabilitation 1104 Wesley Avenue Bryan, OH 43506

F 0760 Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00150277, Complaint Number OH00150284, and Complaint Number OH00150769 and is an example of continued non-compliance from the survey completed on 01/11/24. Residents Affected - Few 365830 Page 2 of 2