Health inspection·December 11, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, staff interview, and facility policy review, this facility failed to ensure appropriate care and monitoring was in place for a resident who was receiving medication for high blood pressure including the administration of blood pressure medication, personalized care plan for management of hypertension, and monitoring residents blood pressure to ensure the effectiveness of medication. This affected one (Resident #85) of the four residents reviewed for medication administration. The facility census was 79. Residents Affected - Few Findings include: Review of the medical record for Resident #85 revealed an admission date of 11/01/2023. Diagnoses included alcohol abuse, dysphasia, hypertension, hemorrhagic stroke (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain usually caused by high blood pressure and trauma), and lack of coordination. Review of the Social Services Initial assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Review of the physician orders for November 2024 for Resident #85 revealed an order for Nifedipine (calcium channel blocker) extended release 60 milligram (mg) tablet, give one tablet every evening for hypertension. Review of the medication administration records for November 2024 revealed the medication Nifedipine ER 60 mg should have started on the evening of 11/01/2024 but was not administered until the evening of 11/02/2024. Review of progress notes revealed no evidence to support the physician was contacted and made aware that the ordered medication Nifedipine ER 60 mg was not available to be administered on the evening of 11/01/2024. Review of Resident #85's hospital discharge documents revealed and order for this resident to continue the medication Nifedipine 60 mg tablet, take one table at nighttime. Last administration time was on 10/31/2024 at 9:19 A.M. Vital signs were to be monitored per facility protocol. Continued review revealed a personalized stroke treatment plan where this resident was noted to have experienced a hemorrhagic stroke (bleeding in the brain). Risk factors for this included high blood pressure. Review of the facility's emergency medication box which was a supply of medication that the Page 1 of 2 366094 366094 12/11/2024 Continuing Healthcare of Gahanna 167 North Stygler Road Gahanna, OH 43230

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility have on hand in case a resident runs out of a specific medication or is newly admitted and the ordered medication had not been received from the pharmacy yet, revealed the medication Nifedipine ER 60 mg was not available to be administered and was not a medication that was kept in this emergency medication box. Review of Resident #85's care plan revealed there was no personalized care plan related to the diagnosis of hypertension or related to the use of hypertension medications. Review of Resident #85's documented vital signs revealed his blood pressure had only been documented as checked on 11/02/2024 resulting 133/65 mmHg, on 11/18/24 resulting 130/67 mmHg, and on 11/30/2024 resulting 115/74 mmHg. Interview on 12/10/2024 at 12:45 P.M. with Director of Nursing (DON) verified Resident #85 did not receive his Nifedipine 60 mg on the evening of 11/01/2024 after being admitted to the facility. The DON also verified that there was no documentation in this resident's medical record to indicate that the physician was notified that this medication was not available to be administered. The DON claimed that it is normally an understanding with the Medical Director that when a resident admits to the facility, that if the medication is not available that it will be administered the next scheduled day. The DON verified that when a resident is receiving hypertension medication for a diagnosis of hypertension, there should be a care plan in place for this. Per DON, the facility does not have a standing policy or protocol related to when to monitor vital signs. Review of the facility policy titled Care Planning, revised 06/2019 revealed that a comprehensive care plan is developed within seven (7) days of completion of the comprehensive assessment. This deficiency represents non-compliance investigated under Complaint Number OH00160008. 366094 Page 2 of 2