Health inspection·July 26, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #156's Lyrica pain medication was available for administration to meet the needs of the resident and the medical record accurately reflected the pain medication administered. This finding affected one (Resident #156) of four residents reviewed for medication administration. Residents Affected - Few Findings include: Review of Resident #156's medical record revealed the resident was admitted on [DATE] and discharged home on [DATE] with diagnoses including diabetes, spinal stenosis and Guillain-Barre syndrome (a rare disorder in which your body's immune system attacks your nerves). Review of Resident #156's Minimum Data Set (MDS) 3.0 assessment revealed the resident exhibited intact cognition. Review of Resident #156's physician orders revealed an order dated [DATE] for Lyrica (used to treat pain caused by nerve damage) 225 mg (milligrams) give one capsule every twelve hours for pain due at 09:00 A.M. and 9:00 P.M. Review of Resident #156's Lyrica 225 mg Controlled Drug Administration Record form with administration dates from [DATE] to [DATE] revealed 30 tablets were delivered to the facility and the last dose was administered on [DATE] at 9:48 P.M. Review of Resident #156's medication administration records (MARS) from [DATE] to [DATE] revealed Lyrica pain medication due on [DATE] at 9:00 A.M. was documented as administered and the dose due on [DATE] at 9:00 P.M. was documented as OT. The MARS indicated OT was the documentation code for other. Review of Resident #156's medication pass progress note dated [DATE] at 8:33 PM. revealed Lyrica 225 mg give one capsule by mouth every twelve hours was on hold and waiting on pharmacy. Review of Resident #156's certified nurse practitioner (CNP) progress note dated [DATE] at 9:23 A.M. revealed the patient was seen at the request of nursing for complaints of numbness and tingling. On exam, the patient was concerned about worsening numbness and tingling to the upper and lower extremities. He stated he had been taking Lyrica for 7.5 years and never missed a dose. The prescription was renewed per a discussion with nursing and the medication was delivered to the unit while the CNP was on the unit. Page 1 of 2 366229 366229 07/26/2023 Parkside Villa 7040 Hepburn Road Middleburg Heights, OH 44130

F 0697 Level of Harm - Minimal harm or potential for actual harm Review of the pharmacy delivery manifest form dated [DATE] at 9:48 A.M. revealed 30 capsules of Resident #156's Lyrica pain medication were delivered to the facility. Review of Resident #156's Lyrica 225 mg Controlled Drug Administration Record form with administration dates from [DATE] to [DATE] revealed the first dose was administered on [DATE] at 10:00 A.M. Residents Affected - Few Interview on [DATE] at 12:50 P.M. with the Director of Nursing (DON) revealed Resident #156 was admitted on [DATE] and on [DATE], the resident required another prescription for Lyrica as the previous prescription had expired and Lyrica 225 mg was not available in their starter box of medications. The DON confirmed Resident #156 was not administered the Lyrica pain medication on [DATE] at 9:00 P.M. because the medication was not available to administer to the resident. An email was sent on [DATE] at 4:01 P.M. to the Administrator to clarify the documentation on Resident #156's MAR which indicated the resident was administered a dose of Lyrica on [DATE] at 9:00 A.M.; however, the medication was not available in the facility to administer to the resident. She confirmed the concern would be investigated and she would respond promptly. Telephone interview on [DATE] at 10:03 A.M. with the DON confirmed Registered Nurse (RN) #823 mistakenly documented Resident #156's Lyrica 225 mg as administered on [DATE] at 9:00 A.M. when the medication was not available in the facility for the resident's use. Review of the undated Administration Procedures for All Medications indicated to administer medications in a safe and effective manner. Review of the Unavailable Medications policy dated 09/18 indicated medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock, a drug recall, manufacturer shortage or the medication may no longer be produced. The facility must make every effort to ensure that medications were available to meet the needs of each resident. This deficiency represents non-compliance investigated under Complaint Number OH00144424. 366229 Page 2 of 2