Health inspection·August 15, 2024

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to ensure the pharmacy provided necessary pain medications timely which resulted in Resident 2 experiencing significant pain, and prompting emergent medical intervention. The facility failed to ensure physician ordered medications were available from the pharmacy for two of four residents reviewed (Residents 2 and 3). Findings include: Review of Resident 2's progress note of July 27, 2024, revealed resident was admitted at approximately 1:30 p.m. Review of the clinical record included diagnoses of, but not limited to, Postlaminectomy Syndrome (pain that continues after a Laminectomy [surgery that reduces pressure on the nerves in the spinal cord] or other spinal surgery, fusion of the spine (surgery to connect two or more bones in any part of the spine), lumbar region (lower back) , and injury of Cauda Equina (bundle of spinal nerves and spinal nerve rootlets). Review of Resident 2's physician's admission orders included an order for MS Contin (morphine medication used to treat moderate to severe pain) oral tablet extended release 100 milligrams (mg), one tablet two times a day for chronic pain, oxycodone HCl (opiod medication used to treat moderate to severe pain) oral tablet 30 mg two tablets every four hours as needed for breakthrough pain, and hydromorphone HCl (opiod medication used to treat moderate to severe pain) oral tablet 4 mg two tablets every eight hours as needed for severe pain if no relief from oxycodone. Additional order received to monitor resident for pain every shift. Resident 2 also had an order for Acetaminophen (pain reliever for mild to moderate pain) 325 mg two tablets every six hours as needed for pain. Review of the July 2024 Medication Administration Record (MAR) for Resident 2, revealed a pain level of 10 (scale of 0-10, 0 means no pain, 10 worst pain) recorded for nite. Further review of Resident 2's MAR revealed that MS Contin was not administered at 9:00 p.m. because it was on hold'. The MAR also indicated that Acetaminophen was not administered. Review of Resident 2's progress note of July 27, 2024, at 23:46 (11:46 p.m.) revealed Residents' routine and prn narcotics were not delivered on the last run. Scripts were faxed by day shift nurse at 1515 [3:15 p.m.] and refaxed at 1725 [5:25 p.m.] on 7/27/24. This RN (Registered Nurse) attempted to pull the medications from the pixus [pyxis - medication dispensing system] with no success. Resident is on high doses of multiple narcotics. Pixus does not have the right dose and enough dose to administer. Resident is in severe pain and requesting to go back to the hospital. [Attending Physician] made aware and is agreeable. ADON (Assistant Director of Nursing] made aware. Spouse is at bedside. Resident left the building at 2320 [11:20 p.m.] with all of his belongings. Resident went to [local Page 1 of 2 395740 395740 08/15/2024 West Chester Rehabilitation and Healthcare Center 800 West Miner Street West Chester, PA 19382

F 0755 hospital]. Level of Harm - Actual harm Review of Resident 3's clinical record revealed that the resident was admitted on [DATE], with diagnoses of, but not limited to, Nontraumatic Subarachnoid Hemorrhage (bleeding in the space between the brain and tissue covering the brain), and fracture of lumbosacral spine and pelvis (lower back connecting to the lower part of the trunk). Residents Affected - Few Review of Resident 3's admission orders included an order for Donepezil HCl (medication used to treat confusion related to Alzheimer's disease) oral tablet 10 mg one tablet once a day for psychotherapeutic, Tamsulosin HCl 0.4 mg one capsule one time a day for genitourinary agents (used to treat conditions of the urinary tract), and Levetiracetam (used to treat seizures) 500 mg one tablet twice a day for anticonvulsant. Review of Resident 3's July 2024 MAR revealed that Donepezil HCl, Tamsulosin HCl, and Levetiracetam were not adminstered on July 13, 2024. Review of progress note of July 13, 2024, indicated awaiting pharmacy delivery. Review of Resident 3's July 2024 MAR revealed that Donepezil HCI, Tamsulosin HCI, and Levetiracetam were not administered at HS (bedtime) resulting in 1 missed dose of each medication. Interview with the Assistant Director of Nursing on August 15, 2024, confirmed the above medications were not available for administration. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 5/6/24 28 Pa. Code: 211.9 (a)(1) Pharmacy services 395740 Page 2 of 2