Health inspection·January 11, 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, observations, staff interview, policy review and review of the Standards of safe medication administration by a certified medication aide, the facility failed to ensure medications were administered by the staff member who prepared the medications. This affected one (#45) of four residents reviewed for medication administration. The facility census was 76. Finding include: Review of the medication record for Resident #45 revealed an admission on [DATE] with diagnoses including but not limited to hypoatremia, anemia, hypertensive orthostatic hypotension renal disease, dementia, and depression. Review of the quarterly Minimum Data Assessment (MDS) assessment dated [DATE] for Resident #45 revealed a brief interview for mental status revealing severe cognitive impairment. Resident #45 required moderate assistance with bed mobility, transfers, and toileting. Resident #45 required set up assistance for meals. Review of the plan of care for Resident #45 revealed the resident had impaired cognition and impaired decision making skills related to dementia. Interventions included administer medication as ordered, cue and reorient as needed and engage the resident is simple structured activities. Review of the physician orders for Resident #45 for the month of January 2024 revealed the resident was scheduled to receive Amlodipine five milligrams (mg) one tablet by mouth, fiber-lax 625 mg by mouth, vitamin B-12 micrograms (mcg) one tablet, digoxin 0.125 mg one tablet by mouth, omeprazole 20 mg tablet by mouth, vitamin D-3 1000 units one tablet by mouth, escitalopram 10 mg one tablet by mouth, sodium chloride one gram (gm) by mouth, questran four gm-one packet mixed with water and metoprolol tartrate 25 mg by mouth. Observation on 01/11/24 at 9:00 A.M. of Licensed Practical Nurse (LPN) #69 prepare the medications for Resident #45. LPN #69 prepared Amlodipine, fiber-lax, vitamin B-12, digoxin, omeprazole, vitamin D-3, escitalopram, sodium chloride, questran, and metoprolol tartrate and placed them in a medication administration cup. LPN #69 then handed the medication cup with medications to the Medication Aide (MA-C) #96 who was not present at the time of medication preparation. MA-C #96 then entered the room of Resident #45 and administered the medication to resident. Interview on 01/11/24 at 9:10 A.M. with LPN #69 verified that MA-C #96 did not prepare the medication for Resident #45. LPN #45 additionally verified she documented in the medical record that she Page 1 of 2 366040 366040 01/11/2024 Doverwood Village 4195 Hamilton Mason Road Hamilton, OH 45011

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administered the medication not the MA-C and stated MA-C trusted her to prepare the correct medications for administration. Interview on 01/11/24 at 9:12 A.M. with MA-C #96 verified she did not know what medications she was administering to Resident #45 and confirmed she did not prepare the medication following the guidelines for a MA-C (medication name, medication dose, medication expiration date and stored and supplied according to the administrative code). Interview on 01/11/24 at 10:30 A.M. with the Administrator verified LPN #69 did not follow the facility policy regarding the use of a medication aide. Further interview with the Administrator verified the LPN #69 should not have prepared and provided the medication for MA-C #96 to administer and additionally should not have signed that she administered the medication when she did not. Review of the standards of safe medication administration by a certified medication aide dated 02/01/2014 of the Ohio Revised Code states immediately after administering a medication the certified medication aide shall accurately document in the residents medical record the following information: the name of the medication and dosage administered, the route of the administration, the date and time of the administration and the name of the certified medication aide administering the medication. Review of the facility policy titled Administration Oral Medications dated 12/2021 stated the nurse/medication aide will cross check the following reference points to ensure accuracy from the physician orders, medication administration record, and label on drug container for accuracy. This deficiency is based on incidental findings discovered during the course of this complaint investigation. 366040 Page 2 of 2