Health inspection·August 29, 2019

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident and or representative were provided with written documentation upon transfer and/or discharge to the hospital. This affected two (#46, #48) of two residents reviewed for hospitalizations. The facility census was 47. Findings include : 1. Review of the medical record for Resident #46 revealed an admission date of 06/25/19. Diagnoses included pneumonia, multiple sclerosis, chronic respiratory failure and severe sepsis with septic shock. Review of the nurses notes dated 07/21/19 and 07/30/19 revealed Resident #46 was sent to the emergency room. Review of the medical record revealed no documentation of a notice of the transfer was given to the resident and or representative. Interview with the Administrator on 08/28/19 at 2:25 P.M. verified they did not provide a reason for transfer notice to Resident # 46 for either of his discharges to the hospital on [DATE] or 07/30/19. The Administrator stated the facility does have a form for discharge and transfers which has not been utilized. 2. Review of the medical record for Resident #48 revealed an initial admission date of 05/22/19, with an re-entry date of 06/10/2019, and a discharge date of 06/25/2019. Diagnoses included acute mastioditis, mass, and lump , severe protein malnutrition and acute kidney failure Review of the nurses notes for Resident #48 dated 06/22/2019 at 9:53 A.M. revealed resident was sent to the emergency room. A nurses note dated 06/25/2019 8:30 P.M. revealed the nurse received an order to send the resident out to emergency room. Review of the medical record revealed no documentation of a notice of the transfer was given to the resident and or representative. Interview with the Administrator on 8/29/19 08:15 A.M. verified there is no notice of transfer completed when Resident #48 went to the hospital on [DATE] and 06/25/19 as the facility doesn't do the notices. Review of the facility's policy titled Transfer and Discharge Requirements, dated 08/16/18, Page 1 of 6 366144 366144 08/29/2019 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

F 0623 Level of Harm - Minimal harm or potential for actual harm revealed the purposed as being to assure protection of elder transfer and discharge rights associated with initiated transfers and discharges. The procedure is for the facility to notify the elder and representative of the transfer and or discharge for reason for the move in writing and in a language they understand. Residents Affected - Few 366144 Page 2 of 6 366144 08/29/2019 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on medical record review, staff interview, and facility policy review, the facility failed to ensure a care plan was revised following a resident elopement. This affected one resident (#14) of twelve residents reviewed for care plans. The facility census was 47. Findings Include: Review of Resident #14's medical record revealed an admission date of 07/06/17. Diagnoses included vascular dementia with behavioral disturbance, paranoid personality disorder, anxiety disorder, restlessness and agitation, repeated falls, and depressive disorder. Review of Resident #14's Minimum Data Set (MDS) assessment, dated 06/26/19, revealed the resident to have severe cognitive impairment. The resident was assessed to wander/elopement alarm daily. Review of Resident #14's nurse's note dated 08/22/19 revealed the resident was found outside of a fenced area in her wheelchair. Review of Resident #14's care plan on 08/26/19 revealed the care plan did not have a revision to include an intervention after an elopement that occurred on 08/22/19. Interview on 08/27/19 at 10:32 A.M. with Registered Nurse (RN) #206 verified Resident #22's care plan had not been updated after the elopement incident that occurred on 08/22/19. 366144 Page 3 of 6 366144 08/29/2019 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, interview and review of facility policy, the facility failed to ensure oxygen tubing was dated for one (#23) of one resident reviewed for respiratory care. The facility identified 11 residents utilizing oxygen therapy. The facility census was 47. Residents Affected - Few Findings include: Review of the medical record for Resident #23 revealed an admission date of 03/02/17. Diagnoses included Parkinson's disease, major depressive disorder with severe psychotic symptoms, osteoarthritis, anxiety disorder, type two diabetes mellitus, hypertension, atrial fibrillation, chronic kidney disease-stage three, vascular dementia with behaviors, paranoid schizophrenia, athersclerotic heart disease, gastroesophageal reflux disease, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment, dated 07/10/19, revealed Resident #23 had intact cognition. Observation on 08/26/19 at 1:27 P.M. revealed an oxygen concentrator present in Resident #23's room. The nasal cannula tubing connected to the oxygen concentrator was not dated. Interview and observation on 08/27/19 at 3:39 P.M. with Licensed Practical Nurse (LPN) #200 confirmed the nasal cannula oxygen tubing connected to the oxygen concentrator was not dated. Interview on 08/27/19 at 5:15 P.M. with the Director of Nursing (DON) additionally confirmed oxygen tubing was to be changed on a weekly basis. Review of a facility policy titled Oxygen Therapy, with a review date of 12/12/16, revealed the oxygen company will change the nasal cannula and tubing weekly. 366144 Page 4 of 6 366144 08/29/2019 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

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. Based on medical record review, staff interview, review of pharmacy recommendations, and review of facility policy, the facility failed to ensure an as needed psychotropic medication had a specific duration of use beyond the 14 days for one (#5) of five reviewed for unnecessary medications. The census was 47. Findings include: Review of the medical record for Resident #5 revealed an admission date of 03/19/19. Diagnoses included generalized anxiety disorder. Review of the physician's orders dated 03/22/19 revealed an order for the antianxiety medication Ativan 0.5 milligram (mg), give 0.5 mg by mouth every six hours as needed (prn) for anxiety, up to three times a day. Review of pharmacy recommendation dated 04/04/19 for Resident #5 revealed the resident was receiving Ativan 0.5 mg every six hours prn. CMS regulations stipulate the to use prn medication beyond 14 days, a prescriber must believe the order should be extended, and document the clinical rationale and specific duration. The duration of use did not have any documentation on the order. This form was signed by the physician on 04/04/19 and no further instructions were written on the recommendation or in the medical record. Interview on 08/27/19 at 2:48 P.M., the Director of Nursing verified there was not an end date to Resident #5's as needed Ativan. The physician signed the recommendation but did not add a duration of use. Review of the facility's policy titled Monitoring Appropriate Use of Antipsychotic Medications, revised date of 03/23/18, revealed elders will use antipsychotic drugs only if it is necessary to treat a specific condition as diagnosed and documented in the clinical record. Procedure number 11 reads prn psychotropic medications orders are limited to 14 days. To extend a prn order beyond 14 days a prescriber must document clinical rationale in the medical record and indicate the intended duration of prn order. 366144 Page 5 of 6 366144 08/29/2019 Mennonite Memorial Home 410 W Elm Street Bluffton, OH 45817

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 observation, staff interview, medical record review, and facility policy review, the facility failed to ensure medications were properly stored/disposed of after a resident refusal. This affected one (#22) of five residents observed during medication administration. The facility census was 47. Findings include: Review of Resident #22's medical record revealed an admission date of 10/18/12. Diagnoses included dementia with behavioral disturbance, anxiety disorder, dysphagia, paranoid personality, restlessness, and agitation. Review of Resident #22's Minimum Data Set (MDS) assessment, dated 07/10/19, revealed the resident had severe cognitive impairment. Review of Resident #22's Medication Administration Record (MAR) dated August 2019 revealed the following medications were to be administered in the morning, duloxetine 60 milligrams (mg) orally, Synthroid 50 micrograms (mcg) orally, Buspar 20 mg orally, Haldol 0.25 milliliters (ml) orally, Tylenol 650 mg orally, Ativan 1 mg orally, and Tramadol 50 mg orally. Observation on 08/28/19 at 8:10 A.M. of medication administration revealed, Licensed Practical Nurse (LPN) #202 had crushed Resident #22's morning medications and put the medications in pudding. LPN #202 then attempted to administer the crushed medications to the resident and the resident refused to take the medications. LPN #202 then proceeded back to the medication cart. LPN #202 wrote the resident's name on the medication cup and put the medication cup in the drawer of the cart. Interview on 08/28/19 at 8:15 A.M. with LPN #202 stated she put Resident #22's medications back in the medication cart and was going to attempt to give the medications to the resident at a later time. Review of facility policy titled Medication Administration, dated 10/22/07, revealed medications are administered at the time they are prepared. Medications are not pre-poured. 366144 Page 6 of 6