Health inspection·February 8, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow the physician orders related to medication administration for one of 3 residents reviewed (Residents R1). Residents Affected - Few Findings include: Review of Resident R1's clinical record indicated admission date January 29, 2024, and had diagnoses including ventricular tachcardi (is a type of abnormal heart rhythm (arrhythmia) characterized by a rapid heartbeat originating from the heart's lower chambers, the ventricles), coronary artery disease (cad) (condition characterized by the narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart muscle), heart failure, atrial fibrillation, (which is the most common type of heart arrhythmia). Review of physician orders indicated that Resident R1 was prescribed Melatonin 9 milligrams (mg) one a day in the evening on January 29, 2024 Interview conducted on February 8, 2024, at 10:12 a.m. with License nurse, unit manager, Employee E5 confirmed that the facility policy for medication administration was the following: Morning medication 9:00 a.m. and administered one hour prior or after. Afternoon medication 5:00 p.m. and could be administered one hour prior or after. Night Medications: 9:00 p.m. and could be administered one hour prior or after. Review of Resident R1's February 2024 Medication Administration Record with License nurse, unit manager Employee E5 revealed that Melatonin 9 mg was not administered to the resident during the evening shift on February 4, 2024, and there was no reason documented for not administering the medication. On February 8, 2024, at approximately 11:00 a.m. an interview was conducted with License nurse, Employee E4 who was assigned to Resident R1 on February 4, 2024, during the evening shift and reported that Melatonin medication was out, and she placed an order to the pharmacy. This was not documented in the clinical file. Facility receives medication on daily bases from the pharmacy to be administered for Resident R1. On February 20, 2024, at 2:48 p.m. a telephone interview was conducated with the pharmacist, Employee E6 who confirmed that the facility did not electronically request this medication on February 4, Page 1 of 2 395515 395515 02/08/2024 Willowcrest Albert Einstein Med Ctr Philadelphia, PA 19141

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2024. It further revealed that facility did have Accudose grab machine stored in their medication room on the unit which has frequent medication supply and Melatonin was one of the medications that pharmacy stores for Accudose grab machine. Further clinical records reviewed that Resident R1 had a physician order on January 30, 2024, to received Hydrolazine 50 mg every 8 hours. Review of January 2024 Medication Administration Report (MAR) revealed this medication was not given on January 31, 2024, at 1:00 p.m. License Nurse unit manager, Employee E3 reported on February 8, 2024 at approximately 11:00 a.m. that she was assigned to the cart and unsure why the medication was not administered. There was no documentation in the clinical record to document the reason for a missing medication. Further clinical record review indicated a physician order obtained January 29, 2024, for Amiodarone 200 mg daily once a day. This medication was administered on January 30, 2024, at 10:10 a.m. by the License nurse, Unit Manager, Employee E5 who had to step in as there was a call out on the cart; therefore, the medication was late. On February 8, 2024, at approximately 2:30 p.m. [NAME] President, Employee E1 and Medical Director, Employee E6 both confirmed above medications were not administered based on the physician order. 28 Pa Code 211.12(d)(5) Nursing services 395515 Page 2 of 2