Health inspection·September 6, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to administer insulin as ordered. This affected three (Resident #7, #8, #9) of eight residents who required insulin. The census was 75. Residents Affected - Few Findings include: Review of the medical record for Resident #7 revealed an admission date of 11/22/22. Diagnoses included type two diabetes mellitus with diabetic nephropathy and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/17/23, revealed Resident #7 had intact cognition. Review of the physician order dated 06/23/23 revealed Resident #7 was ordered Novolog 100 units/milliliters per sliding scale before meals. Review of the medication administration record (MAR) dated August 2023 revealed no documentation indicating Resident #7's blood sugar was checked, or insulin was administered the mornings of 08/05/23 or 08/06/23. Review of the nurse progress note dated 08/06/23 timed 12:19 P.M. and 12:20 P.M. revealed Registered Nurse (RN) #102 documented Resident #7 did not receive the morning dose of Novolog 100 units per sliding scale on 08/05/23 and 08/06/23. Review of the medical record for Resident #8 revealed an admission date of 10/24/22. Diagnoses included type two diabetes with diabetic polyneuropathy and chronic kidney disease. Review of the quarterly MDS assessment, dated 06/19/23, revealed Resident #8 had intact cognition. Review of physician order dated 10/25/22 revealed Resident #8 was ordered Lispro solution six units one time a day with breakfast. Review of the MAR dated August 2023 revealed no documentation indicating Resident #8's blood sugar was checked, or insulin was administered with breakfast on 08/05/23 or 08/06/23. Review of the nurse progress note dated 08/06/23 at 1:59 P.M. revealed RN #102 documented Resident #8 did not receive the morning dose of Lispro six units with breakfast on 08/05/23 and 08/06/23. Review of the medical record for Resident #9 revealed an admission date of 11/02/22. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction and type two diabetes with other circulatory complications. Review of the quarterly MDS assessment, dated 07/11/23, revealed Resident #9 had impaired cognition. Page 1 of 2 366440 366440 09/06/2023 Highland Pointe Health & Rehab Center 402 Golf View Lane Highland Heights, OH 44143

F 0760 Level of Harm - Minimal harm or potential for actual harm Review of physician order dated 07/30/23 revealed Resident #9 was ordered Novolog 100 unit/milliliter per sliding scale. Review of the MAR dated August 2023 revealed no documentation indicating Resident #9's blood sugar was checked, or insulin was administered the mornings of 08/05/23 and 08/06/23. Residents Affected - Few Review of the nurse progress note dated 08/06/23 at 11:17 A.M. revealed RN #102 documented Resident #9 did not receive the morning dose of Novolog 100 units per sliding scale on 08/06/23. Interview on 09/06/23 at 11:52 A.M. with the Director of Nursing and Corporate Nurse verified the above findings. They indicated all the residents on the 400/500 hallway received their oral medications but Residents #7, #8 and #9 did not have their blood sugars checked and did not receive their insulin on the mornings of 08/05/23 and 08/06/23. Interview on 09/06/23 at 4:15 P.M. with RN #102 revealed residents were stating, upon her arrival to work on 08/06/23 that they did not receive their morning medications. RN #102 verified blood sugars were not checked and insulin was not administered as ordered for Residents #7, #8, and #9 on 08/05/23 and 08/06/23. This deficiency represents non-compliance investigated under Complaint Number OH00145645. 366440 Page 2 of 2