Health inspection·September 12, 2023

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 interview and record review the facility failed to ensure Resident #50 was free from significant medication errors. This affected one resident (#50) of three residents medication administration. The facility census was 87. Residents Affected - Few Findings include: Review of the medical record for Resident #50 revealed an admission date of 12/08/22. Diagnoses included hypertensive heart disease with heart failure, anemia, history of other venous thrombosis and embolism, acute diastolic (congestive heart failure), depression, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, supraventricular tachycardia, unspecified fall, muscle weakness, difficulty in walking, weakness, repeated falls, unspecified protein-calorie malnutrition, and other lack of coordination. Review of the Minimum Data Set (MDS) assessment, dated 06/16/23, revealed the resident had intact cognition. Resident #50 required limited assistance of two for bed mobility, total with two assists for transfers and toileting, dressing and hygiene extensive with one assist, and eating supervision with one assist. Resident #50 was incontinent of bowel and bladder. Review of the care plan dated 06/16/23 revealed Resident #50 has acute/chronic pain related to depression, right femur fracture, status post-surgery, and bilateral foot drop. Interventions included monitor and record pain characteristics every shift and as needed (PRN), monitor, record, and report and signs and symptoms of verbal pain, monitor, record complaints of pain or requests for pain treatment. Review of physician orders dated for 07/27/23, revealed Resident #50 was ordered Oxycodone, narcotic pain medication, 5 milligrams (mg) three times a day (TID) straight. Review of Resident #50's medication administration records (MAR) for August 2023 revealed resident did not receive Oxycodone on 08/27/23 at 1400 hours (2:00 P.M.), 08/27/23 at 2200 hours (10:00 P.M.), and on 08/28/23 at 0600 hours (6:00 A.M.). Review of Resident #50's narcotic sign out sheet for August 2023 revealed no Oxycodone 5 mg was signed out for on 08/27/23 at 1400 hours (2:00 P.M.), 08/27/23 at 2200 hours (10:00 P.M.), and on 08/28/23 at 0600 hours (6:00 A.M.). Review of the Medicine Dispense document for August 2023 revealed no Oxycodone 5 mg was dispensed for Resident #50 on 08/27/23 at 1400 hours (2:00 P.M.), 08/27/23 at 2200 hours (10:00 P.M.), and on Page 1 of 2 366491 366491 09/12/2023 Strongsville Healthcare and Rehabilitation 18936 Pearl Road Strongsville, OH 44136

F 0760 08/28/23 at 0600 hours (6:00 A.M.). Level of Harm - Minimal harm or potential for actual harm Review of Resident #50's MAR for September 2023 revealed resident was administered Oxycodone on 09/01/23 at 2200 hours (10:00 P.M.) and on 09/02/23 at 0552 hours (5:52 A.M.). Residents Affected - Few Review of Resident #50's narcotic sign out sheet for September 2023 revealed no Oxycodone 5 mg was signed out for on 09/01/23 at 22:01 hours (10:01 P.M.) and on 09/02/23 at 0552 hours (5:52 A.M.) Review of the Medicine Dispense document for September 2023 revealed no Oxycodone 5 mg was dispensed on 09/01/23 at 22:01 hours and on 09/02/23 at 0552 hours. Review of the prescription for Oxycodone 5 mg give TID for chronic pain revealed it was signed by a certified nurse practitioner (CNP) on 8/28/23. The order did not indicate a time it was signed by the CNP. Interview on 09/06/23 at 11:20 A.M. with Resident #50 revealed she did not receive her oxycodone, narcotic pain medication all the time as ordered by the physician for chronic pain. Interview on 09/11/23 at 11:16 A.M. with the Regional Nurse Consultant (RNC) #212 confirmed Resident #50's MARS did not contain documentation the ordered Oxycodone had been administered on 08/27/23 and 08/28/23. RNC #212 reported the CNP did not sign the prescription until 08/28/23. RNC #212 confirmed the oxycodone on 09/01/23 and 09/02/23 was not administered as ordered. Interview on 09/11/23 at 12:18 P.M. with RNC #212 further confirmed the signature on the order was not timed, but reported the CNP must have signed after morning some time because the 2:00 P.M. does was given on 08/28/23. Interview on 09/12/23 at 1:36 P.M. via phone with Licensed Practical Nurse (LPN) #217, agency nurse, revealed she accidentally signed the MARS for September 2023 for 09/01/23 at 22:01 hours (10:01 P.M.) and for 09/02/23 at 0552 hours (05:52 A.M.) by error. LPN #217 reported she told the supervisor working that day and supervisor reported she was unable to pull from the [NAME] (machine with stock medications and narcotics). LPN #217 reported she documented in the progress notes for 09/01/23 at 10:01 P.M. medication on order and on 09/02/23 at 5:52 A.M. medication on order. This deficiency represents non-compliance investigated under Complaint Number OH00146017. 366491 Page 2 of 2