Health inspection·April 20, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policy and procedure, clinical records and documentation provided by the facility, it was determined that the facility failed to ensure residents were free from significant medication errors causing harm of hospitaization to one of eighteen residents reviewed (Resident 230). Residents Affected - Few Findings include: Review of facility policy and procedure titled Medication Administration revealed The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band; checking photograph attached to medical records and if necessary, verifying resident identification with other facility personnel. Additional review of the Medication Administration policy revealed The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Further review of the Medication Administration policy revealed the following information is checked/verified for each resident prior to administering medications: a) allergies to medications; and (b) vital signs if necessary. Review of Resident 230's diagnosis list revealed diagnoses including acute respiratory failure with hypoxia, Chronic Kidney Disease (failure of the kidneys to function properly), and Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 230's allergy list included allergies to Baclofen (muscle relaxant) and Gabapentin (anti-seizure and nerve pain medication). Review of Resident 230's clinical progress notes dated December 7, 2022, revealed [nurse practitioner] made aware of med error, patient was given another patient's medication. Gabapentin which causes patient to hallucinate and Baclofen which causes restless leg syndrome and insomnia in patient. New verbal order received and noted. RP [representative] needs to be made aware 12/8/2022. Neuro checks time 72 hours. Further review of Resident 230's clinical progress notes dated December 8, 2022, revealed This RN [Registered Nurse] and DON [Director Of Nursing] assessed [resident] this morning. [resident] was laying in her bed appeared to be sleeping, attempts made to arouse her via verbal and tactile stimuli. She was unresponsive, blood sugar 108, BP [blood pressure] 111/59, HR [heart rate] 68, pulse ox Page 1 of 2 395326 395326 04/20/2023 Zerbe Sisters Nursing Center, 2499 Zerbe Road Narvon, PA 17555

F 0760 [oxygen saturation in blood] 94% with periods of apnea. [nurse practitioner] notified order to start oxygen at 2 liters and transport to ED [emergency department] for further evaluation. Level of Harm - Actual harm Residents Affected - Few Review of hospital documentation dated December 8, 2022, revealed resident presented to the hospital with altered mental status after being administered Gabapentin 400 mg [milligram], Baclofen 20 mg and Melatonin 9 mg and found to be unresponsive this morning and had to be intubated for airway protection. Review of hospital history and physical documentation dated December 8, 2022, revealed given wrong medications at SNF [skilled nursing facility], became obtunded [reduced level of alertness or consciousness], intubated December 8, 2022, extubated December 9, 2022. Review of hospital admitting diagnosis dated December 8, 2022, revealed acute hypoxemic respiratory failure. Review of Resident 230's clinical record revealed that Resident 230 was readmitted to the facility on [DATE]. Review of facility documentation dated December 7, 2022, revealed [nurse] gave [resident] another resident's medication. [Resident] has allergy to baclofen and gabapentin. Interview with the Nursing Home Administrator and Director of Nursing on April 20, 2022, revealed that Resident 230 was administered another resident's medication on December 7, 2022, which resulted in Resident 230 becoming unresponsive and being transferred to an acute care facility. The facility failed to ensure residents were free from significant medication errors causing hospitalization, intubation and harm to Resident 230. 28 Pa. Code 211.12(c)(d)(1)(3) Nursing Services Previously cited 5/12/2022 395326 Page 2 of 2