Health inspection·March 7, 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, staff interview, review of the hospice contract, and review of the facility policy, the facility failed to ensure pain medications were available for a resident experiencing pain and discomfort at the end of life. This affected one (Resident #32) of three residents reviewed for pain management. The facility census was 28. Findings include: Review of the medical record for Resident #32 revealed an admission date of 01/10/18 and a discharge date of 02/12/24. Diagnoses included Parkinson's disease, dementia, and chronic kidney disease (CKD). Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was admitted to hospice services. Resident #32 was cognitively impaired. Review of the physician orders for Resident #32 revealed an admission date to hospice care on 02/07/24, and morphine sulfate 20 milligram (mg)/milliliter (ml) and give 0.5 ml every two hours for pain and/or shortness of breath (SOB), written on 02/09/24 at 2:50 P.M. Review of the nursing notes dated 02/08/24 untimed, revealed Resident #32 was medicated for pain with Tylenol (treats mild pain), awaiting order at this time, and pain noted with turning/providing care. The nursing note dated 02/09/24 untimed, revealed during morning care, Resident #32 was reluctant to move and moaned and grimacing with each movement. Hospice notified and aware, will address each issue and notify the power of attorney (POA). The nursing note dated 02/10/24, untimed, revealed Resident #32 exhibited increased discomfort still awaiting medications/physician order clarification on call notified. The nursing note dated 02/10/24 at 12:16 A.M. revealed Resident #32's morphine medication did not arrive with delivery from pharmacy, spoke with pharmacy and they informed me that the quantity needed clarified and new e-script in order to fill. Hospice contacted and updated with the clarification needs and updated that Resident #32 was in pain. Hospice followed up confirming they sent the clarification and e-script in. The nurse then called pharmacy and requested an authorization from the pharmacist to pull medication from the starter box, technician confirmed that they did receive it and sent request as urgent. After not hearing back a second request was made, now stating they needed the Page 1 of 2 366031 366031 03/07/2024 Mill Manor Care Center 983 Exchange St Vermilion, OH 44089

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few same clarification again. The nurse informed the technician that both of them and hospice confirmed again expressed the need for medication and multiple attempts have been made since approximately 7:00 P.M. and it was now 12:16 A.M. The nursing note dated 02/11/24 at 12:50 A.M. revealed the pharmacist called and gave authorization to pull medication, and medication administered and effective. Review of Resident #32's Medication Administration Record (MAR) for February 2024 revealed the first dose of morphine sulfate was administered on 02/11/24 at 12:55 A.M. and was effective. Interview on 03/05/24 at 12:09 P.M. with Licensed Practical Nurse (LPN) #111 stated there was an issue with getting pain medication for Resident #32 when she was ordered morphine. LPN #111 stated the physician order needed clarification and it took some time to get it corrected and once it was corrected she was working and pulled it immediately gave the resident something for pain. Interview on 03/05/24 at 3:53 P.M. with Pharmacist #144 stated the original order was written on 02/09/24 at 1:56 P.M. for morphine sulfate 20 mg/ml to give 15 ml bottle. The pharmacy called the provider for updated order to change quantity bottle from 15 ml to 30 ml due to facility inhouse stock. Pharmacist #144 stated clarification order was obtained on 02/10/24 at 7:53 P.M. and corrected the order per pharmacy request. Pharmacist #144 stated the pharmacy cannot fill an opioid without the order being exactly correct. Pharmacist #144 stated this would be considered to have been a delay of treatment if the resident was experiencing pain per the medical records. Review of the facility policy titled Pain Management, updated 04/2023, revealed the facility identifies each resident at risk for pain and/or experiencing actual pain and adequately plans care and implements procedures to reduce the risk for pain. If pain occurs, the nurse will assess for type and location including pain scale rating and as needed (PRN) pain medication will be administered as ordered. Review of the facility policy titled,Contingency/Starter Medication Supply dated 09/2017 revealed accuscripts pharmacy will provide limited, customized supplied of medication that may be needed to initiate therapy before the next scheduled delivery occurs. For controlled medications, a valid control prescription must be present in order for a contingency/starter supply to be utilized. Schedule II prescriptions must be written by a physician or certified nurse practitioner with a DEA license designated for C-II and faxed to the pharmacy. A valid prescription consists of the following: valid date not older than six months for a schedule III-V or 60 days for a schedule II, patient name, date of birth , and address, drug information with drug name, strength, form, directions, quantity, and refills (refills are not valid on Schedule II prescriptions.), physician information name, address, signature, phone number, DEA number. Review of the hospice contract dated 01/2024, revealed hospice will obtain orders for pain medication and medications needed to palliate symptoms from the primary care physician and/or the hospice medical director. This deficiency represents non-compliance investigated under Master Complaint Number OH00151079 and Complaint Number OH00150991. 366031 Page 2 of 2