Health inspection·February 29, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure narcotic medications were removed from circulation when discontinued and accounted appropriately, resulting in one unaccounted oxycodone pill for Resident #94. This affected one resident (#94) of three residents reviewed for controlled medication administration. The facility census was 93. Findings Include: Record review of Resident #94 revealed the resident was admitted on [DATE] and discharged on 02/09/24. Diagnoses included atrial fibrillation, Crohn's disease, and anxiety disorder. The most recent order for oxycodone (a narcotic pain medication) was discontinued on 12/25/23. Review of the medication administration record revealed no evidence the medication was given after this date. Review of the facility investigation documentation revealed a photograph of a medication card including one rectangular pill in the pouch labeled '17'. The pills in all other visible pouches were round. No identifiers were visible in the photograph. The facility also furnished a photograph of a drug record sheet for Resident #94's oxycodone tablets. This sheet had one medication documented removed on 12/31/23 signed by what appeared to be Licensed Practical Nurse (LPN) #602, leaving 16 oxycodone pills remaining in the card. Interview with the Director of Nursing (DON) and Administrator on 02/27/24 at 8:57 A.M. revealed the facility performed an investigation regarding incorrect pills being taped into a medication card for a resident. The facility actual count of the medication matched the documentation of how many pills should remain, excluding the taped-in pill. Interview with Registered Nurse #301 on 02/27/24 revealed she conducted an investigation following report of an incorrect medication being taped into the medication card for Resident #94's oxycodone. She tried to question the last nurse to care for the resident (LPN #602) who did not return her calls. Due to this, the facility contacted her agency, informed them of the event, and asked that she not return to the facility. Registered Nurse #301 then audited narcotic storage with no other discrepancies detected. The alleged event occurred the night of 01/17/24. Interview with the DON on 02/27/24 at 3:32 P.M. revealed facility investigation revealed the actual count of remaining oxycodone pills for Resident #94 was correct, only the taped-in pill made it incorrect. LPN #602 had a habit of writing sloppily in the narcotic book; however, when the facility did narcotic counts, no discrepancies were noted. Page 1 of 2 365845 365845 02/29/2024 Rae Ann Suburban 29505 Detroit Rd Westlake, OH 44145

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with LPN #502 on 02/28/24 at 9:40 A.M. revealed she was the nurse who followed LPN #602's shift on 01/18/24. No concerns were identified with the narcotic count; however, she later identified an incorrect pill was taped in Resident #94's oxycodone card and notified her management. This had no effect on Resident #94 as the oxycodone order had previously been discontinued. Interview with the Administrator and DON on 02/28/24 at 9:55 A.M. verified that Resident #94's oxycodone remained in their medication cart for multiple weeks after the order was discontinued, an oxycodone pill was signed out on 12/31/23 despite no active order for the resident, and the facility could not identify the final disposition of the medication due to it not being documented as wasted or administered. Interview with LPN #602 on 02/28/24 at 10:55 A.M. revealed she denied knowledge of any incorrect pill being taped into a medication card and said she would not do that. She did not recall drawing or giving oxycodone on 12/31/23 to Resident #94 or wasting the medication. She said when wasting narcotic medications, they were to do it in the presence of another nurse as witness. Review of the facility's controlled substances policy dated 04/2019 revealed controlled medications were to be reconciled on receipt, administration, and disposition. When not given, they were to be wasted in the presence of a witness who would co-sign the disposal. This deficiency represents noncompliance investigated under Complaint Number OH00150464. 365845 Page 2 of 2