Health inspection·March 29, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of clinical records, review of select forms and documents, and staff interview, it was determined that the facility failed to ensure an effective procedure for acquiring and dispensing medications for five of six residents reviewed (Residents 1, 2, 3, 4, and 6). Findings include: Documents provided by the Director of Nursing on March 29, 2024, at 9:30 AM identified the procedure for obtaining medications for new admissions, effective March 18, 2024, indicates that if the facility orders medications by 11:00 AM, the pharmacy will depart at 2:20 PM to deliver Monday through Friday. If orders are completed by 9:00 PM, pharmacy will depart at 12:30 AM to deliver Monday through Friday. The procedure also indicates that there is a 5 Step Order Process in which nursing staff shall determine what time the resident medication is due, then determine when the delivery time would be for the pharmacy. If the delivery time is after the time the dose is due, staff are to determine availability of the medication from their Omnicell (a backup inventory of medications stored on-site in the facility). If the medication is not available in the Omnicell, staff should call the prescriber and get the medication changed to something available on site or call the pharmacy to request the medication be delivered STAT (immediately). Interview with the Director of Nursing at this time, revealed that there is a local pharmacy that can be utilized if medications cannot be completed STAT. Review of Resident 1's clinical record revealed that she was admitted to the facility on Thursday, March 28, 2024, at 11:57 AM. A physician's order dated March 28, 2024, indicated nursing staff were to administer Morphine (a narcotic pain reliever) ER (extended release) 15 mg (milligrams) at 8:00 PM for pain. Review of Resident 1's Medication Administration Record (MAR, a form utilized to document the administration of medication) dated March 2024, indicated that Resident 1's Morphine was not administered due to awaiting arrival. A list provided by the facility to indicate what medications are available for dispensing in the Omnicell indicated that Morphine ER 15 mg was available, but still not given to Resident 1 when due for administration. Review of Resident 2's clinical record revealed that the facility admitted her on Tuesday, March 26, 2024, at 3:56 PM. Nursing progress notes dated March 26, 2024, from 9:16 PM till 9:20 PM, indicated that the following medications were not administered in the evening due to them not being available from pharmacy: Colestipol (lowers cholesterol), Dorzolamide (an eye drop that can treat glaucoma), Pilocarpine (an eye drop that can treat glaucoma), Advair (treat lung conditions), Latanoprost (an eye drop that can treat glaucoma), and Simvastatin (lowers cholesterol). There was no documented Page 1 of 2 395678 395678 03/29/2024 Williamsport Home, The 1900 Ravine Road Williamsport, PA 17701

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some evidence to indicate that the facility completed the 5 Step Order Process to obtain Resident 2's medications, or if nursing staff attempted to obtain the medications through the facility's on-site Omnicell. Review of Resident 3's clinical record revealed that the facility admitted her on Tuesday, March 26, 2024, at 12:13 PM. Nursing progress notes dated March 26, 2024, from 9:21 PM till 9:28 PM, indicated that the following medications were not administered in the evening due to them not being available from pharmacy: Advair, Flonase (a nasal spray to help with allergies), Bumetanide (helps control excess fluid in the body), and Sucralfate (helps with stomach ulcers). There was no documented evidence to indicate that the facility completed the 5 Step Order Process to obtain Resident 3's medications. Review of Resident 4's clinical record revealed that the facility admitted her on Monday, March 25, 2024, at 11:45 AM. A nursing progress note dated March 25, 2024, at 6:53 PM, indicated that nursing staff did not administer Acyclovir (an antiviral agent) as ordered by her physician at 5:00 PM, due to having not arrived from pharmacy and not available in Omnicell. Review of the list of provided by the facility to indicate what medications are available for dispensing in the Omnicell indicated that Acyclovir is a medication that should be available. There was no further documented evidence to indicate that the facility completed the 5 Step Order Process to obtain Resident 4's Acyclovir. Review of Resident 6's clinical record revealed that the facility admitted her on Wednesday, March 27, 2024, at 4:19 PM. A nursing progress note dated March 28, 2024, at 2:27 PM, indicated that nursing staff did not administer her Lidocaine patch (for pain relief) at 9:00 AM due to still awaiting its arrival from pharmacy, 22 hours after Resident 6 was admitted to the facility. Interview with the Administrator and Director of Nursing on March 29, 2024, at 11:30 AM confirmed the above findings for Resident 1, 2, 3, 4, and 6. 483.45 Pharmacy Services Previously cited 2/2/24 28 Pa. Code 211.9 (j.1)(4)(5) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395678 Page 2 of 2