Health inspection·November 4, 2024

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, staff interview, medical record review, and policy review the facility failed to ensure insulin pens were primed before administering insulin to the residents. This affected one resident (#23) of one resident reviewed for insulin pen priming. The facility identified five residents (#14, #15, #18, #19 and #23) in House #2 who received insulin. The facility census was 54. Residents Affected - Few Findings included: Medical record review for Resident #23 revealed an admission date of 01/20/23. Medical diagnoses included chronic obstructive pulmonary disease and diabetes. Review of physician orders dated 11/02/23 revealed Lantus to inject 35 units subcutaneously in the morning. Further review of physician orders dated 01/31/24 for Resident #23 revealed Novolog flex pen subcutaneous solution to inject per sliding scale in the morning and at bedtime. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact. During a medication administration observation on 11/04/24 at 8:21 A.M. for Resident #23 revealed after her blood sugar was taken she required two units of Novolog and she was scheduled for Lantus 35 units. The Registered Nurse (RN) #171 didn't prime either one of the pens before administration. Interview with RN #171 on 11/04/24 at 8:38 A.M. revealed he didn't know anything about an insulin pen needed primed before giving the medication. He confirmed he didn't prime the needles for Novolog or Lantus. Review of policy entitled Insulin Pen Quick Reference Guide dated 2021 revealed Novolog and Lantus require two units to prime the needle before injecting the insulin. Review of the manufacturer's guidelines entitled Drop Safe Safety Pen Needle not dated revealed to perform a priming test recommended by the pen inject device manufacturer. A drop of liquid should appear on the needle tip visible through the viewing window. Use a new safety pen needle if the priming was unsuccessful. This deficiency represents non-compliance as an incidental finding during investigation of Complaint Number OH00159371. Page 1 of 3 366430 366430 11/04/2024 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview and policy review the facility failed to ensure glucometers were sanitized between residents. This affected three (#14, #15, #23) of three residents reviewed for medication administration. The facility identified this had the potential to affect five residents (#14, #15, #18, #19 and #23) who received accuchecks in House #2. The facility census was 54. Residents Affected - Few Findings included: 1. Review of the medical record review for Resident #14 revealed an admission date of 11/18/22. Medical diagnoses included Alzheimer's Disease and diabetes. Review of physician orders dated 11/18/23 revealed to take blood sugars in the morning. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 was rarely or ever understood. During a medication administration observation on 11/04/24 at 7:38 A.M. for Resident #14 revealed after taking the blood sugar of the resident the Registered Nurse (RN) #171 revealed he didn't wipe the glucometer off with any sanitizing wipes. 2. Medical record review for Resident #15 revealed an admission date of 08/12/20. Medical diagnoses included cerebrovascular attack (CVA) and diabetes. Review of physician orders dated 09/13/23 revealed to take blood sugar three times a day before meals and at bed time. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. During a medication administration observation on 11/04/24 at 7:56 A.M. for Resident #15 revealed after taking the blood sugar of the resident the RN #171 revealed he didn't wipe the glucometer off with any sanitizing wipes. 3. Medical record review for Resident #23 revealed an admission date of 01/20/23. Medical diagnoses included chronic obstructive pulmonary disease and diabetes. Review of physician orders dated 11/02/23 revealed Lantus to inject 35 units subcutaneously in the morning. Further review of physician orders dated 01/31/24 for Resident #23 revealed Novolog flex pen subcutaneous solution to inject per sliding scale in the morning and at bedtime. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #23 was cognitively intact. During a medication administration observation on 11/04/24 at 8:21 A.M. for Resident #23 revealed after taking the blood sugar of the resident the RN #171 revealed he didn't wipe the glucometer off with any sanitizing wipes. 366430 Page 2 of 3 366430 11/04/2024 Otterbein Gahanna 402 Liberty Way Gahanna, OH 43230

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with RN #171 on 11/04/24 at 8:38 A.M. revealed the facility was using the alcohol swabs to clean off the glucometer's. He confirmed he didn't sanitize the glucometer's in between residents for Resident's #14, #15, and #23. Review of policy entitled Cleaning/Disinfecting Elder Equipment and Medical Devices dated 11/05/21 revealed resident care devices - such as electric thermometers, glucose monitoring devices and coagulation monitoring devices may transmit pathogens if devices contaminated with blood and body fluids are shared without cleaning and disinfecting between uses for different residents. Single use disposable devices and individually assigned equipment should be used whenever possible. If equipment is required to be shared, it will be cleaned or disinfected between elders. This deficiency represents non-compliance as an incidental finding during investigation of Complaint Number OH00159371. 366430 Page 3 of 3