Health inspection·December 18, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on medical record review, review of hospital records, staff interviews and policy review, the facility failed to ensure a therapeutic medication interchange was reconciled timely resulting in a significant medication error for the resident's diabetic medication (insulin). This resulted in Actual Harm when Resident #102 did not receive her insulin as ordered on 11/20/22 which resulted in Resident #102 being admitted to the hospital with a high blood sugar reading of 964 milligrams (mg)/ deciliter (dL). This affected one (#102) out of the three residents reviewed for medications administration. The facility census was 85. Findings included: Review of the medical record for Resident #102 revealed an admission date of 11/17/22 with medical diagnoses of protein calorie malnutrition, diabetic mellitus with ketoacidosis, dysphagia, and senile degeneration of the brain. Review of the medical record revealed Resident #102 was discharged to the hospital on [DATE] with altered mental status. Review of the medical record for Resident #102 revealed a discharge Minimum Data Set (MDS), dated [DATE], which indicated Resident #102 had short term memory loss and had modified independence with decision making. The MDS stated Resident #102 required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the medical record for Resident #102 revealed a physician order, dated 11/18/22 for Humalog solution (insulin) 100 units per milliliter (ml) per sliding scale, to inject insulin subcutaneous (SQ) before meals and every evening for diabetes mellitus. The sliding scale stated if blood sugar was 151-200 to give two units; 201-250 to give four units; 251-300 to give six units; 301-350 to give eight units; 351-400 to give 10 units and if blood sugar 401+ call medical director (MD). Review of the medical record revealed a physician order, dated 11/20/22 for Humalog Kwikpen 100 units/ml solution pen-injector. The order stated to inject before meals and every evening for diabetes mellitus per sliding scale. The sliding scale stated if blood sugar was 151-200 to give two units; 201-250 to give four units; 251-300 to give six units; 301-350 to give eight units; 351-400 to give 10 units and if blood sugar 401+ call MD. Review of the medical record for Resident #102 revealed the November 2022 Medication Administration Record (MAR) which indicated Resident #102 received her insulin as ordered on 11/19/22 but did not contain documentation to support the facility checked Resident #102's blood sugar levels or that Resident #102 was administered insulin on 11/20/22. Page 1 of 4 366208 366208 12/18/2023 Residence at Huntington Court 350 Hancock Avenue Hamilton, OH 45011

F 0760 Level of Harm - Actual harm Residents Affected - Few Review of the medical record for Resident #102 revealed a nurse progress note, dated 11/21/22 at 9:32 A.M., which stated the nurse spoke with the resident around 7:30 A.M. and resident was noted to be sleepy but was able to answer questions. The note continued to state at 9:30 A.M. therapy staff reported Resident #102 was too sleepy for therapy. The note stated the nurse went to check on Resident #102 and to give medications and the resident was noted to be lethargic and not able to answer questions. The note stated the nurse called the physician and reported Resident #102's change of condition and a new order was received to send to the hospital. Vital signs were taken and blood sugar level before nine-one-one (911) arrived. Resident #102's blood sugar level was noted to be high. Review of the medical record for Resident #102 revealed a transfer out of facility assessment, dated 11/21/22, which stated Resident #102 was sent out to the hospital due to altered mental status change and recent fall. The assessment indicated the last recorded blood sugar was 333 ml/dL on 11/19/22. Review of the medical record revealed an emergency department (ED) report, dated 11/21/22, stated Resident #102 was seen in the ED for hyperglycemia. The report stated Resident #102 presented to ED with alert eyes and attempted to speak but was not easily understood. The lab work in the ED revealed a blood glucose level of 964 mg/dL and Resident #102 was diagnosed with hyperosmolar hyperglycemic state, dehydration, and metabolic encephalopathy. The note continued to state Resident #102 was admitted to the hospital. Interview with Administrator on 12/13/23 at 1:35 P.M. confirmed the medical record for Resident #102 did not contain documentation to support the facility staff checked Resident #102's blood sugar levels or administered insulin on 11/20/22. Administrator stated the pharmacy recommended a therapeutic interchange from Humalog insulin per sliding scale to Humalog Kwikpen injector per sliding scale on 11/19/22 but the nurses did not confirm the new order for the Humalog Kwikpen in Resident #102's electronic health record. Administrator stated since the nurses did not confirm the order for the Humalog Kwikpen, the insulin did not appear on the MAR for the nurses to check Resident #102's blood sugar levels or administer insulin on 11/20/22. Administrator stated the facility identified the concern related to therapeutic medication interchanges and insulin administration and completed all nursing staff education on 11/21/22 and 11/22/22. Review of the facility policy titled, Medication Administration, dated 06/21/17, stated the nurse was responsible for noting any changes on the MAR and medications would be administered by legally authorized and trained persons consistent with accepted standards of practice. The deficient practice was corrected on 12/09/22 when the facility implemented the following corrective actions: • On 11/21/22, Resident #102 was transferred to a local hospital via emergency medical services after the physician was notified of a change of condition. • On 11/21/22, immediate education was provided to Director of Nursing (DON) by corporate clinician on medication administration regarding diabetic residents, admission process, change of condition, therapeutic interchanges, and signs and symptoms of hyper/hypoglycemia. 366208 Page 2 of 4 366208 12/18/2023 Residence at Huntington Court 350 Hancock Avenue Hamilton, OH 45011

F 0760 • Level of Harm - Actual harm On 11/21/22, Assistant Director of Nursing (ADON) #09/nursing supervisor completed audits on all diabetic orders to ensure they were entered into the electronic health records correctly. Residents Affected - Few • On 11/21/22, DON provided education to all licensed nurses on medication administration regarding diabetic residents and therapeutic interchanges. • On 11/22/22, DON provided education to all licensed nurses on medication administration for diabetic residents, admission process, change of condition, therapeutic interchanges, and signs of hyper/hypoglycemia. • On 11/22/22, DON provided one on one education with ADON #09, unit managers, and nursing supervisors on medication administration for diabetic residents, admission/readmission process, change of condition, therapeutic interchanges, and signs and symptoms of hyper/hypoglycemia. • On 11/22/22, Administrator provided education to Admissions Coordinator on admission process to ensure correct paperwork was given to nurses on admission and readmissions. • On 11/22/22, an initial Quality Assurance and Performance Improvement (QAPI) plan was completed, and monitoring tools were completed weekly for four weeks on admission and readmission process, therapeutic interchange process along with the monitoring of diabetic medication orders to ensure entered in electronic health records correctly. Review of the QAPI revealed all monitoring tools were completed and no issues were noted. • On 11/22/22, Licensed Practical Nurse (LPN) #315, who was responsible for Resident #102's medications on 11/20/22, was terminated for not administering medications as ordered and other non-related issues. • On 12/09/22, all facility QAPI monitoring tools were completed and reviewed. No further issues were identified. • On 12/13/23 two (#100 #104) additional residents medical records were reviewed regarding medication 366208 Page 3 of 4 366208 12/18/2023 Residence at Huntington Court 350 Hancock Avenue Hamilton, OH 45011

F 0760 administration. No concerns were identified. Level of Harm - Actual harm • Residents Affected - Few On 12/13/23 between 8:41 A.M. and 11:18 A.M., LPN #300 and LPN #275 were observed passing medications to Resident #51, #55 and #63. No medication errors were observed. • Interviews on 12/13/23 from 3:34 P.M. to 3:37 P.M. with LPN #275 and #311 confirmed the facility provided education in November 2022 on therapeutic medication interchanges, medication administration for diabetic residents, and signs and symptoms of hyper/hypoglycemia. This deficiency represents non-compliance investigated under Complaint Number OH00148476. 366208 Page 4 of 4