Health inspection·May 22, 2023

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, medication instruction sheet review, and staff interview, the facility failed to ensure the medication error rate was less than five percent. There were 30 opportunities with two errors for a medication error rate of 6.66 percent. This affected one (#51) of four residents reviewed for medication administration. The facility census was 93. Residents Affected - Few Findings include: Record review revealed Resident #51 was admitted on [DATE], with diagnoses of: osteomyelitis left ankle and foot and type two diabetes mellitus with neuropathy. Review of physicians order dated 04/11/23 revealed an order for Insulin Glargine subcutaneous solution pen-injector 100 unit/milliliter (ML) inject 40 units subcutaneously two times a day for hyperglycemia. Review of physicians orders dated 04/19/23 revealed an order for Humalog Kwikpen 100 unit/ml solution pen-injector inject as per sliding scale, if blood sugar (BS): 151 - 200 = 2 units; 201 - 250 = 4 units; 251 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, >401 give 12 units and notify med one, subcutaneously before meals and at bedtime for diabetes mellitus type two. Observation on 05/22/23 at 8:34 A.M., revealed Licensed Practical Nurse (LPN) #14 administering medications to Resident #51 including insulin glargine insulin injection pen and Humalog Kwikpen insulin injection pen. LPN #14 took Resident #51 blood sugar, and it was 457 milligrams/deciliter (mg/dL). LPN #14 called the physician and got a verbal order to give 14 units sliding scale Humalog insulin and recheck the blood sugar in an hour. LPN #14 dialed the insulin glargine pen to 40 and the Humalog Kwikpen to 14 per the doctor's instruction, LPN #14 failed to prime either insulin pen before giving the injection. Interview on 05/22/23 at 10:00 A.M., with LPN #14 verified she did not prime the insulin glargine pen and the Humalog Kwikpen insulin pens for Resident #51 prior to administration. LPN #14 stated she thought you only primed the insulin pens when you first open a new pen. Review of an undated Humalog Kwikpen instructions revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and a 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should Page 1 of 4 366387 366387 05/22/2023 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0759 see insulin at the tip of the needle. If you do not see insulin, repeat priming steps no more than four times. Level of Harm - Minimal harm or potential for actual harm Review of an insulin glargine lantus instruction guide dated 2022 revealed to perform a safety test dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform. Residents Affected - Few the test. If no insulin comes out, repeat the test two more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection and never use the pen if no insulin comes out after using a second needle. This deficiency is an example of noncompliance for Complaint Number OH00142706. 366387 Page 2 of 4 366387 05/22/2023 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, medication instruction sheet review, and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#51) of four residents reviewed for medication administration. The facility census was 93. Residents Affected - Few Findings include: Record review revealed Resident #51 was admitted on [DATE], with diagnoses of: osteomyelitis left ankle and foot and type two diabetes mellitus with neuropathy. Review of physicians order dated 04/11/23 revealed an order for Insulin Glargine subcutaneous solution pen-injector 100 unit/milliliter (ML) inject 40 units subcutaneously two times a day for hyperglycemia. Review of physicians orders dated 04/19/23 revealed an order for Humalog Kwikpen 100 unit/ml solution pen-injector inject as per sliding scale, if blood sugar (BS): 151 - 200 = 2 units; 201 - 250 = 4 units; 251 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, >401 give 12 units and notify med one, subcutaneously before meals and at bedtime for diabetes mellitus type two. Observation on 05/22/23 at 8:34 A.M., revealed Licensed Practical Nurse (LPN) #14 administering medications to Resident #51 including insulin glargine insulin injection pen and Humalog Kwikpen insulin injection pen. LPN #14 took Resident #51 blood sugar, and it was 457 milligrams/deciliter (mg/dL). LPN #14 called the physician and got a verbal order to give 14 units sliding scale Humalog insulin and recheck the blood sugar in an hour. LPN #14 dialed the insulin glargine pen to 40 and the Humalog Kwikpen to 14 per the doctor's instruction, LPN #14 failed to prime either insulin pen before giving the injection. Interview on 05/22/23 at 10:00 A.M., with LPN #14 verified she did not prime the insulin glargine pen and the Humalog Kwikpen insulin pens for Resident #51 prior to administration. LPN #14 stated she thought you only primed the insulin pens when you first open a new pen. Review of an undated Humalog Kwikpen instructions revealed to prime the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Push the dose knob in until it stops and a 0 is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps no more than four times. Review of an insulin glargine lantus instruction guide dated 2022 revealed to perform a safety test dial a test dose of two units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform. the test. If no insulin comes out, repeat the test two more times. If there is still no insulin 366387 Page 3 of 4 366387 05/22/2023 Darby Glenn Nursing and Rehabilitation Center 4787 Tremont Club Drive Hilliard, OH 43026

F 0760 Level of Harm - Minimal harm or potential for actual harm coming out, use a new needle and do the safety test again. Always perform the safety test before each injection and never use the pen if no insulin comes out after using a second needle. This deficiency is an example of noncompliance for Complaint Number OH00142706. Residents Affected - Few 366387 Page 4 of 4