Health inspection·March 12, 2020

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 observations, staff interview and record review, the facility failed to obtain a physician order for a resident's hand splint (Resident #28). The deficient practice effected one (Resident #28) of two residents (Resident #7 and Resident #28) reviewed for limited range of motion. The facility census was 62. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed an admission date on 07/30/07 with diagnoses including Alzheimer's Disease, aphasia, macular degeneration, other specified diseases of anus and rectum, osteoarthritis, hypothyroidism, other iron deficiency, stiffness of left knee, disorder of bone, hyperlipidemia, persistent vegetative state, hypertension, contracture of right and left knees, Vitamin B12 deficiency, major depressive disorder, leiomyome of uterus, unspecified psychosis not due to a substance or known physiological condition, pain in joints of hand, contracture of unspecified hand, abnormal posture, muscle weakness and dysphagia. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was never or rarely understood. Per staff assessment, the resident had severely impaired cognition. The resident required extensive assistance from one to two staff to complete bed mobility, dressing, eating, toileting and personal hygiene. The resident was totally dependent on staff assistance to complete bathing, mobility and transfers. The resident was always incontinent of bladder and bowel. The resident was on a turning and repositioning program. Review of the progress notes for Resident #28 dated 12/18/19 revealed the resident continued to maintain flexible joints with the restorative maintenance program which included splint or brace and passive range of motion. Review of Resident #28's care plan dated 01/05/2012 revealed the resident had altered functional range of motion of bilateral hands related to contractures with an interventions that included: bilateral elbow, wrist and shoulder and lower extremity passive range of motion exercise program once a day, six to seven days per week for at least fifteen minutes per day and use of supportive devices such as splints, braces, canes, crutches, etcetera as recommended by occupational therapy. Review of Resident #28's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the past three months revealed no documentation of the use of a hand splint. Review of Resident #28's current physician orders revealed there was not a physician order for the use of hand splints. Page 1 of 4 366135 366135 03/12/2020 Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219

F 0684 Level of Harm - Minimal harm or potential for actual harm Observations of Resident #28 on 03/10/20 at 9:14 A.M. and 6:10 P.M. revealed the resident had a splint on her left hand. Observations of Resident #28 on 03/11/20 at 10:04 A.M., 12:24 P.M., and 4:35 P.M. revealed the resident was up in her custom wheelchair without the hand splint in place at the times of each of the observations. Residents Affected - Few Interview with the Assistant Director of Nursing (ADON) on 03/11/20 at 3:03 P.M. confirmed there should be a physician order in place for any kind of adaptive equipment, including a splint. Interview with State Tested Nurse Aide (STNA) #152 on 03/11/20 at 4:40 P.M. revealed Resident #28 wore a splint on her hand in the morning and then once the resident was out of bed, the splint was removed. STNA #152 confirmed the resident was not wearing a splint due to the resident being up in her wheelchair. STNA #152 stated the physical therapist provided instructions on when the resident should have the splint on and when it should be taken off. Resident #28 did not sleep with the splint on. The aide was not aware whether a physician order was in place for the splint. Interview with Registered Nurse (RN) #150 on 03/11/20 at 4:53 P.M. revealed physical therapy provided an in-service to staff regarding Resident #28's restorative nursing program and recommended the use of the splint. RN #150 stated the resident should have the splint on her hand when she is out of bed and it should be taken off when the resident was in bed. RN #150 stated the resident's physician approved the use of the splint, but there should also be an order with instructions in the resident's chart. RN #150 confirmed there was not a physician order in the resident's chart for the use of the hand splint. 366135 Page 2 of 4 366135 03/12/2020 Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219

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** Based on record review and interview, the facility failed to ensure the physician provided a rational for declining a gradual dose reduction of psychotropic medications for Residents #30 and #33. This affected two of five residents reviewed for unnecessary medications. Facility census was 62. Findings include: 1. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including major depressive disorder and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 had severe cognitive impairment. The MDS also revealed the resident received an antidepressant. Review of pharmacy note dated 12/18/19 revealed a pharmacy recommendation was made for an updated progress note for the continued need of Resident #30's Prozac (antidepressant). Review of the pharmacy consultation report dated 12/18/19 revealed a recommendation for an annual review to update the progress note regarding the continued need for Prozac 20 milligram (mg) daily. The Centers of Medicare and Medicaid (CMS) required an annual consideration for a gradual dose reduction (GDR) for residents that received antidepressant medications. If the medication was to continue at the current dose, a resident-specific rational was to be provided describing why a dose reduction was clinically contraindicated. On 01/03/20, the physician marked the box to decline the recommendation because the GDR was clinically contraindicated as indicated below. There was a note to check option #1 or #2 AND provide a patient-specific rationale. The physician checked option #1 which indicated the medication was to be continued, and a GDR was likely to impair the individual function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW. The physician signed the form but did not provided a patient-specific rationale to describe why a GDR attempt would likely impair function or cause psychiatric instability for Resident #30. Review of March 2020 physician orders revealed Resident #30 had received Prozac 20 mg daily for depression since 03/10/05. Interview on 03/12/20 at 5:17 P.M. Director of Nursing (DON) verified the physician did not provide a patient-specific rationale by a GDR should not attempted for Resident #30. 2. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses including dementia, psychosis, anxiety and depressive disorder. Review of the quarterly MDS dated [DATE] revealed Resident #33 had severe cognitive impairment. The MDS also revealed the resident received antipsychotic and antidepressant medication. Review of pharmacy note dated 05/22/19 revealed a pharmacy recommendation was made for an updated progress note for the continued need of Resident #33's Abilify (antipsychotic) 2.5 mg daily and 366135 Page 3 of 4 366135 03/12/2020 Mohun Health Care Center 2340 Airport Dr Columbus, OH 43219

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Zoloft (antidepressant) 25 mg daily. CMS required an annual consideration for a GDR for residents that received antipsychotic and antidepressant medications. If the medication was to continue at the current dose, a resident-specific rational was to be provided describing why a dose reduction was clinically contraindicated. On 06/06/19, the physician marked the box to decline the recommendation because the GDR was clinically contraindicated as indicated below. There was a note to check option #1 or #2 AND provide a patient-specific rationale. The physician checked option #1 which indicated the medication was to be continued and a GDR was likely to impair the individual function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW. The physician signed the form but did not provided a patient-specific rationale to describe why a GDR attempt would likely impair function or cause psychiatric instability for Resident #33. Review of March 2020 physician orders revealed Resident #33 had received Zoloft 25 mg daily since 06/27/17 and Abilify 2.5 mg daily since 10/18/18. Interview on 03/12/20 at 5:17 P.M., the DON verified the physician did not provide a patient-specific rationale why a GDR should not attempted for Resident #33. 366135 Page 4 of 4