Health inspection·May 16, 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 observations, staff interviews, record review, and policy review, the facility failed to ensure narcotics were accurately reconciled. This affected two (Residents #64 and #404) of 19 residents with narcotics medications stored on the Shelter Hall and East Hall odd-side medication carts. The facility census was 105. Findings include: 1. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, severe vascular dementia with anxiety, type II diabetes mellitus, and other chronic pain. Review of the Minimum Data Set (MDS) assessment completed on 03/07/24 revealed Resident #64 had severely impaired cognition, had no behaviors, did not wander, and did not reject care. Review of the physician orders dated 01/04/2024 revealed an order for Morphine sulfate 20 milligrams (mg) per (/) milliliter (ml) solution give 0.25 ml (five mg) under tongue every four hours as needed for pain or shortness of breath. Review of the Controlled Drug Record revealed Resident #64 received 0.25 ml of morphine sulfate 100 mg per five ml (20 mg/ml) solution on 04/21/24 and had 28 ml remaining in the bottle. Observation on 05/15/24 at 11:22 A.M. revealed Morphine sulfate solution for Resident # 64 held an immeasurable amount of medication between 24 ml and 28 ml marks on the bottle. During interviews conducted on 05/15/24 from 11:27 A.M. to 11:43 A.M., Licensed Practical Nurse (LPN) #207 and the Director of Nursing (DON) each verified Resident #64's bottle of morphine sulfate measured below the 28 ml mark. LPN #207 stated nurses completed narcotic counts at the beginning of every shift, and she did not notice the discrepancy that morning. 2. Review of the medical record revealed Resident #404 was admitted to the facility on [DATE]. Diagnoses included senile degeneration of the brain, dementia without behavioral disturbance, and other chronic pain. Review of the admission Minimum Data Set (MDS) assessment completed 04/22/24 revealed Resident #404 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #404 was on Hospice. Page 1 of 2 365889 365889 05/16/2024 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of the physician orders dated 05/03/24 revealed an order for Lorazepam Intensol Concentrate two milligrams (mg) per (/) milliliter (ml) to give 0.25 ml sublingually twice daily for anxiety. Review of the Controlled Drug Record revealed Resident #404 received a 0.25 ml dose of Lorazepam Intensol two mg/ml on 05/15/24 at 9:06 A.M. and had 21 ml remaining in the bottle. Residents Affected - Few Observation on 05/15/24 at 11:54 A.M. revealed Lorazepam Intensol two mg /ml solution for Resident #404 measured at the 20 ml marking. During interviews conducted on 05/15/24 from 11:55 A.M. to 12:05 P.M., the Director of Nursing (DON), Licensed Practical Nurse (LPN) #204, and LPN #198 each verified Resident #404's bottle of Lorazepam Intensol two mg/ml measured at the 20 ml line and should have measured above the 20 ml line. Review of the facility policy titled Controlled Substances, Drug Count, dated 04/2021, revealed two licensed nurses counted and verified the narcotics counts for each individual at the change of shift. If the count was incorrect, the nurse on duty did not leave until the count was correct or the reason for the discrepancy was identified. This deficiency represents noncompliance investigated under Complaint Number OH00153147. 365889 Page 2 of 2