Health inspection·January 12, 2023

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, dementia with severe anxiety, chronic respiratory failure with hypoxia, psychosis, major depressive disorder, generalized anxiety disorder, and insomnia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and required extensive assistance or was totally dependent upon staff for ADLs. Resident #15 received an antipsychotic, antianxiety, antidepressant, a diuretic, and an opioid medication seven times in the seven day look back period. Review of the care plan revealed Resident #15 had the potential for or actual decline in condition related to receiving hospice services, adjustment disorder, depression, grief, and anxiety. Review of a pharmacy recommendation dated 02/23/22 regarding Resident #15's order for Lorazepam (medication used to treat anxiety) 1 mg via peg tube every four hours as needed (PRN) for agitation/anxiety revealed a recommendation that if the physician felt it was appropriate for the PRN order to be extended beyond 14 days, the physician should document rationale and indicate the duration of the PRN order. Further review of the medical record revealed the physician did not address the pharmacy recommendation until 05/02/22. Interview on 01/12/23 at approximately 1:30 P.M. with the Director of Nursing (DON) verified the physician did not address the pharmacy recommendation dated 02/23/22 until 05/02/22. The DON indicated the expectation was for the physician to address the pharmacy recommendation sooner. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure as needed (PRN) antipsychotic medications prescribed were limited to 14 days. Additionally, the facility failed to re-evaluate a resident for continued use of PRN antipsychotic medication. This affected one (Resident #14) of five residents reviewed for psychotropic medications. Additionally, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected one (Resident #15) of five residents reviewed for pharmacy recommendation response. The facility's census was 49. Findings include: 1. Medical record review for Resident #14 revealed an admission date of 07/15/22. Resident #14 was discharged on 08/04/22 and returned on 09/06/22 with diagnoses including but not limited to Page 1 of 4 366084 366084 01/12/2023 Vancrest Health Care Center of Eaton 1600 Park Avenue Eaton, OH 45320

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few respiratory failure, interstitial pulmonary disease, pulmonary fibrosis, peripheral vascular disease, paroxysmal fibrillation, chronic diastolic congestive heart failure, hypotension, polyneuropathy, anxiety, shortness of breath, right bundle block, and diaphragmatic hernia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and required extensive assistance with Activities of Daily Living (ADLs). Resident #14 received antianxiety and antidepressant medications during the assessment period. Review of the plan of care dated 09/12/22 and revised on 10/03/22 revealed Resident #14 was at risk for altered mood pattern related to generalized anxiety disorder. Interventions included administer medications as ordered, explain the importance of taking medication, monitor for signs and symptoms of anxiety, one on one visits as needed, and review medications as needed for recommendations for gradual trial reduction. Review of the hospital discharge orders dated 09/06/22 revealed an order for Ativan (medication used to treat anxiety) 1 milligram (mg) every 12 hours as needed for four days. Review of the physician progress note dated 09/09/22 revealed no documentation the physician re-assessed the resident for the appropriateness Ativan administration. Review of the physician order dated 09/16/22 revealed an order for Ativan 1 mg tablet, give one tablet every twelve hours as needed (PRN) for anxiety, dispense 60 tablets. Further review of the handwritten prescription revealed no stop date was identified. Review of the physician progress note dated 09/30/22 revealed no documentation related to continued use of Ativan. Review of Resident #14's Medication Administration Record (MAR) for September 2022 revealed an order for Ativan 1 mg tablet, give one tablet by mouth as needed for congestive heart failure dated 09/06/22 and discontinued on 10/12/22. Further review of the MAR revealed Ativan was administered on 09/07/22, 09/16/22, 09/17/22, 09/18/22, 09/19/22, 09/20/22, 09/21/22, 09/22/22, 09/23/22, 09/25/22, 09/26/22, 09/27/22, 09/29/22, and 09/30/22. Review of Resident #14's MAR for October 2022 revealed an order for Ativan 1 mg, give one tablet by mouth every 12 hours as needed for congestive heart failure dated 09/06/22 and discontinued on 10/12/22. Ativan was administered on 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/09/22, and 10/10/22. Additional review revealed an order for Ativan 1 mg one tablet by mouth as needed for congestive heart failure dated 10/12/22 and discontinued 10/20/22. Ativan 1 mg by mouth was administered on 10/13/22, 10/14/22, 10/17/22. Further review revealed an order for Ativan 1 mg tablet, give one tablet by mouth every 12 hours as needed for anxiety dated 10/20/22. Ativan 1 mg by mouth was administer on 10/20/22 and 10/21/22. Review of the physician progress note dated 10/29/22 revealed no documentation the physician re-assessed the resident for the appropriateness Ativan administration or justified reasoning for continued Ativan use. Review of physician orders revealed an order for Ativan 1 mg, give one tablet by mouth two times a day for anxiety dated 12/06/22 and discontinued on 12/28/22. An order for Ativan 1 mg tablet, give one by mouth every 12 hours as needed for anxiety dated 12/28/22. 366084 Page 2 of 4 366084 01/12/2023 Vancrest Health Care Center of Eaton 1600 Park Avenue Eaton, OH 45320

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #14's MAR for December 2022 revealed an order for Ativan 1 mg, one tablet by mouth two times a day for anxiety dated 12/06/22 and discontinued on 12/28/22. Resident #14 received Ativan two times a day from 12/06/22 through 12/28/22. Further review of the medical record revealed no documentation PRN Ativan was limited to 14 days. Additional review revealed no documentation the physician re-assessed the resident for the appropriateness of Ativan administration nor was there any documentation alleging the resident required long term use of Ativan. Interview on 01/11/23 at 10:39 A.M. with Licensed Practical Nurse (LPN) #119 verified the order for Ativan dated 09/16/22 was a PRN order and did not have a stop date limiting use to 14 days. Interview on 01/11/23 at 2:10 P.M. with Consulting Pharmacist #69 verified there were no recommendations made for the PRN Ativan in September 2022. Interview on 01/11/23 at 2:19 P.M. with the Director of Nursing (DON) verified the physician progress notes did not contain documentation related to Resident #14 being reassessed for the appropriateness of PRN or continued use for Ativan. Review of the facility policy titled, Antipsychotic Medication Use, dated 12/2016 revealed residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medication, will be evaluated for the appropriateness and indications for use. The facility will re-evaluate the use of antipsychotic medication at the time of the admission or within two weeks to consider whether of not the medication can be reduced, tapered or discontinued. 366084 Page 3 of 4 366084 01/12/2023 Vancrest Health Care Center of Eaton 1600 Park Avenue Eaton, OH 45320

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interview, and review of facility policy, the facility failed to ensure medication carts were secured when unattended. This had the potential to affect four (Residents #4, #12, #26, and #42) identified by the facility as confused and independently mobile residing on the South unit. The facility census was 49. Findings included: Observation on 01/09/23 at 12:20 P.M. revealed the medication cart located on the South unit was unlocked and unattended. Licensed Practical Nurse (LPN) #119 was in a resident's room. Interview on 01/09/23 at 12:30 P.M. with LPN #119 verified the medication cart was unlocked and unattended while she was in a resident's room. Observation on 01/11/23 at 11:21 A.M. revealed the medication cart located on the South unit was unlocked and unattended. Interview on 01/11/23 at 11:29 A.M. with Licensed Practical Nurse (LPN) #119 verified the medication cart was unlocked and unattended in the unit hallway LPN #119 verified the medication cart should be locked when unattended. Review of the facility policy titled Storage of Medication dated 04/2007 revealed compartments containing drugs and biologicals shall be locked when not in use and shall not be left unattended and otherwise potentially available to others. 366084 Page 4 of 4