Health inspection·June 18, 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 medical record review, resident interview, and staff interview the facility failed to ensure resident pain medication was available for administration. This affected one (Resident #39) of three residents reviewed for pain management. The facility census was 38. Findings include: Review of the medical record for Resident #39 revealed an admission date of 05/17/24 at 11:00 A.M. with diagnoses including diabetes mellitus, anxiety disorder, insomnia, hypertensive kidney disease with stage three kidney failure, heart arrhythmia, pneumonia, adult failure to thrive, prostatic hypertrophy, and a history of transient ischemic attack and cerebral infarction (stroke). Review of the physician's orders for Resident #39 revealed an order dated 05/17/24 to administer Lyrica 25 milligrams (mg) in the morning and Lyrica 50 mg orally at bedtime for pain. Review of the Medication Administration Record (MAR) for Resident #39 dated May 2024 revealed the resident missed the following doses of Lyrica due to the medication was not available to be administered: 05/17/24 at 7:00 P.M., 05/18/24 at 7:00 A.M., 05/18/24 at 7:00 P.M. Further review of the MAR revealed Resident #39 did not receive his first dose of Lyrica until 05/19/24 at 7:00 A.M. Interview on 06/13/24 at 7:51 A.M. with Licensed Practical Nurse (LPN) #40 confirmed Resident #39 did not receive the first three scheduled doses of Lyrica upon his admission because the medication wasn't available. LPN #40 confirmed Resident #39 was very upset that he missed doses of Lyrica on the following dates: 05/17/24 at 7:00 P.M., 05/18/24 at 7:00 A.M., 05/18/24 at 7:00 P.M. LPN #40 confirmed the physician needed to transmit a prescription to the pharmacy before they would deliver the medication. She had notified the physician, but the medication wasn't available for administration. Interview on 06/13/24 at 8:06 A.M. with Resident #39 confirmed when he was first admitted the facility was unable to obtain his Lyrica to treat his leg pain and he had been very upset with the situation. Resident #39 stated the facility did administer Tylenol, but it wasn't as effective as the Lyrica medication. Interview on 06/17/24 at 3:10 P.M. with the Administrator confirmed she had received a message from LPN #40 on 05/18/24 that Resident #39 was threatening to leave against medical advice because he had not received his Lyrica. The Administrator confirmed she sent a text message to the physician and the physician responded immediately and sent a text message that she would send an order for the Lyrica via facsimile to the pharmacy. Page 1 of 2 365874 365874 06/18/2024 Hudson Elms Nursing Center 563 W Streetsboro Road Hudson, OH 44236

F 0755 Level of Harm - Minimal harm or potential for actual harm Interview on 06/17/24 at 3:21 P.M. with Pharmacist #41 confirmed the pharmacy received an order for Lyrica from the physician on 05/18/24 at 2:59 P.M. and the pharmacy delivered Resident #39's Lyrica to the facility on [DATE] at 7:54 P.M. This deficiency represents noncompliance investigated under Complaint Number OH00154482. Residents Affected - Few 365874 Page 2 of 2