Health inspection·December 7, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of controlled substance records, staff interview, and review of facility policy, the facility failed to ensure a resident's narcotic medication administration was accurately documented in the medical record. This affected one (#81) of three residents reviewed for narcotic medication administration. The census was 78. Findings include: Review of Resident #81 closed medical record revealed an admission date of 10/16/23. Diagnoses included pubic fracture, dorsalgia, osteoarthritis, and femur fracture. Resident #81 was discharged from the facility on 11/03/23. Review of an admission Minimum data Set (MDS) assessment dated [DATE] revealed Resident #81 was cognitively intact and needed some help with activities of daily living (ADL's). Review of physician orders revealed an order dated 10/16/23 for take 0.5 to one Oxycodone hydrochloride five milligram (mg) tablet (narcotic pain medication) every six hours for pain up to seven days. Review of the facility's Controlled Drug Receipt/Record/Disposition Form revealed one tablet of Oxycodone hydrochloride five mg was documented as being withdrawn on 10/27/23 at 3:30 A.M. Oxycodone hydrochloride five mg was documented as being withdrawn on 10/22/23 at 9:00 A.M. and 10/23/23 at 3:00 A.M. Review of medication administration records (MAR's) revealed no documentation of Oxycodone hydrochloride five mg being administered on 10/17/23 at 3:30 A.M. Oxycodone hydrochloride five mg was documented as being administered on 10/17/23 at 6:25 A.M. Further review of MAR's revealed no documentation of Oxycodone hydrochloride five mg being administered on 10/22/23 at 9:00 A.M. and 10/23/23 at 3:00 A.M. During an interview on 12/06/23 at 10:30 A.M. the Director of Nursing (DON) confirmed the missing and inaccurate documentation in Resident #9's MAR of the Oxycodone medication. The DON had spoken with the nurse responsible for the missing and inaccurate documentation and reported the nurse forgot to log the Oxycodone hydrochloride five mg in the MAR after administering to Resident #9. The DON confirmed all medications administered to residents should be documented in the MAR accurately. Review of the facility;s policy titled Administration of Oral Medications dated revised December Page 1 of 2 366040 366040 12/07/2023 Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011

F 0842 Level of Harm - Minimal harm or potential for actual harm 2021 medications are charted as soon after the administration as possible. The nurse or medication aide will document medication administration, refusal, hold, or other necessary codes. This deficiency represents non-compliance investigated under Complaint Number OH00148080. Residents Affected - Few 366040 Page 2 of 2