Health inspection·October 16, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, and record review, the facility failed to ensure medications were supplied by the pharmacy to be administered per physician order. This affected one (Resident #1) of three residents reviewed for medications. The facility census was 67. Findings include: Record review for Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 included intervertebral disc disorder, arthritis, asthma, and chronic pain. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. Review of Resident #1's care plans dated 07/2023 revealed a focus for resident exhibiting a verbal difficulty with compliance of medication administration. Interventions included assessing for unmet needs, assist the resident with comprehension of policies and regulations, determine cause for behaviors, and observe for triggers to behaviors. Review of the physician orders revealed on 06/30/23, Resident #1 was ordered to receive Humira (immunosuppressive) 40 milligrams (mg) per 0.8 milliliter (ml) subcutaneous injection once a day every two weeks on Friday. Review of the Medication Administration Records (MAR) dated 06/2023 revealed Resident #1 received the Humira shot on 06/30/23 per physician order. On 07/14/23, Resident #1 received one dose of the Humira shot. On 07/28/23, Resident #1 did not receive the Humira shot for the reason charted as 'drug item unavailable, pharmacy to send'. On the 08/11/23, Resident #1 did not receive the Humira shot for the reason documented as 'drug unavailable, pharmacy notified of need to supply-resident to supply'. On 8/25/23, the Humira shot was not administered for the reason documented 'drug unavailable'. On 09/08/23, Resident #1 received the Humira shot per physician order. On 09/22/23, Resident #1 did not receive the Humira shot scheduled for the reason documented 'drug unavailable'. On 10/06/23, Resident #1 did not receive the Humira shot scheduled for the reason documented as 'drug unavailable'. Resident #1 received Humira three times out of eight opportunities. Interview on 10/11/23 at 2:30 P.M. with Resident #1 revealed the resident admitted to having medications from her personal pharmacy brought into the facility. Resident #1 stated she was upset because every time her Humira shot was due, the nurses would tell her it was unavailable. Resident #1 stated she did have her family bring her a Humira shot to her, and she was caught by the nurse with the medication. Resident #1 stated she only was taking the medication herself because she did not believe Page 1 of 2 366384 366384 10/16/2023 Cypress Pointe Health Campus 600 West National Road Englewood, OH 45322

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the facility would supply her with her medication. Resident #1 verified prior to 06/2023, her medications were being supplied as ordered. Interview on 10/16/23 at 11:30 A.M. with the Director of Nursing (DON) revealed Resident #1 often refused medications and would have her family bring in medications from home for her to administer to herself. The DON stated the facility staff educated the resident frequently on how important it was to only take the medications from the facility per order. The DON stated the resident was found to be administering the Humira shot herself at times. The DON stated the resident's personal pharmacy had supplied some of the Humira medications. The DON verified there was missing scheduled doses of the Humira on the reviewed MARs for Resident #1. Interview on 10/16/23 at 3:00 P.M. with the Regional Support (RS) #400 stated he was able to get a pharmacy invoice for Resident #1's Humira medications from her personal pharmacy. The resident's pharmacy had supplied the Humira medications since 11/2022, upon the resident's admission. RS #400 stated he was unsure of how Resident #1 would have gotten the Humira shot to administer to herself unless her family was bringing in the medications and giving them to the resident. RS #400 stated there were no facility pharmacy invoices for Resident #1's Humira medication and there was no evidence the facility pharmacy had supplied any of the Humira while the resident was residing in the facility. RS #400 stated Resident #1 was non-compliant with medications and would often have her family bring in medications not on her medications lists and she would take the medications as she wanted. RS #400 stated the facility staff tried to educate the resident on the importance of not taking medications herself. RS #400 verified there was documentation on the 06/2023, 07/2023, 08/2023, 09/2023, and 10/2023 MARS that the Humira shot was administered and not available for administration. RS #400 verified the only documentation of the resident giving herself the medication was the nursing progress note dated 08/01/23. This deficiency represents non-compliance investigated under Complaint Number OH00146459. 366384 Page 2 of 2