Health inspection·May 31, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, policy review and interview, the facility failed to ensure Resident #1 was free from a significant medication error. This affected one (Resident #1) of three residents reviewed for infections. Residents Affected - Few Findings include: Review of the medical record for Resident #1 revealed an admission date of 09/03/23 with diagnoses of Alzheimer's disease, staphylococcal arthritis right knee, anxiety disorder, delirium, mood disorder, and infection and inflammatory reaction due to internal right knee prothesis. Review of the communication with physician note dated 04/07/23, timed 10:21 A.M. revealed Physician #5 was updated to right knee being red and very warm in comparison to surrounding skin. Resident #1 complained of discomfort to the area. Physician #5 ordered labs and to start doxycycline (an antibiotic) 100 milligrams (mg) by mouth twice a day for 14 days. Review of the April 2023's physician orders revealed doxycycline hyclate 100 mg give one tablet by mouth two times a day for a possible infection right knee for 14 days. Review of the antibiotic therapy care plan, revised on 04/11/23 revealed Resident #1 was on antibiotic therapy related to possible right knee infection with an intervention to administer antibiotic medications as ordered by physician. Review of the April 2023 Medication Administration Record (MAR) revealed Resident #1 was administered doxycycline 100 mg beginning the evening of 04/07/23. Doxycycline 100 mg was administered during the morning and evening medication pass of 04/08/23, 04/09/23, 04/10/23, 04/11/23, 04/12/23, 04/13/23 and 04/14/23. There was a 9 on the morning and evening medication pass slots of 04/15/23 indicating to other/see progress notes signed with the initials of agency Licensed Practical Nurse (LPN) #6 in each slot. Review of the orders - administration note dated 04/15/23, timed 4:52 P.M., authored by agency LPN #6 revealed doxycycline hyclate tablet 100 mg give one tablet by mouth two times a day for possible infection right knee for 14 days. 04/14/23 was 14 days. Review of the orders - administration note dated 04/15/23, timed 4:53 P.M., authored by Agency LPN #6 revealed doxycycline hyclate tablet 100 mg give one tablet by mouth two times a day for possible infection right knee for 14 days. 04/14/23 was 14 days. Review of Physician #5's progress note dated 04/23/23 revealed Resident #1 had fatigue and joint Page 1 of 2 366281 366281 05/31/2023 Windsor House at Champion 200 East Glendola Avenue Champion, OH 44483

F 0760 pain. Level of Harm - Minimal harm or potential for actual harm Review of the communication with physician note dated 04/26/23, timed 12:05 P.M. revealed Physician #5 updated regarding right knee being red with yellow puss-like drainage. Per Physician #5, send resident to the emergency room for evaluation/treatment. Residents Affected - Few Interview on 05/31/23 at 10:45 A.M. with Registered Nurse (RN) #1 verified Resident #1 received seven days of doxycycline 100 mg instead of 14 days during April 2023. Interview on 05/31/23 at 11:30 A.M. with the Director of Nursing (DON), with LPN #2 present revealed the DON spoke to agency LPN #6 regarding the discontinuing of Resident #1's doxycycline on 04/15/23. Agency LPN #6 stated to the DON that agency LPN #6 read the order as 14 doses instead of 14 days. The DON verified Resident #1's doxycycline was not administered as ordered since the antibiotic was only given for seven days instead of the ordered 14 days. Observation on 05/31/23 at 1:40 P.M. revealed Resident #1 was lying in bed with a knee immobilizer on her right leg. RN #1 removed the immobilizer, elastic wrap, Kerlix wrap and dressing over Resident #1's right knee wound. Resident #1 had an approximate 12-inch surgical incision extending from above her right knee to below her right knee. Interview, during the observation, with Resident #1 was attempted however Resident #1 was cognitively impaired and unable to answering questions. Review of the facility's Medication Administration policy revised March 2023 revealed check/review the paper medications administration record or EMAR (electronic medication administration record) for medication administration orders and instructions. (If needed, follow instructions). This deficiency represents non-compliance investigated under Complaint Number OH00143044. 366281 Page 2 of 2