Health inspection·October 30, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents are free of significant medication errors for one of four residents reviewed (Resident 4). Residents Affected - Few Findings include: Clinical record review for Resident 4 revealed nursing documentation dated October 26, 2024, at 1:38 PM, noting Employee 1 (licensed practical nurse) went into the resident room to administer medications to Resident 3 in bed A. Documentation revealed Resident 3 was being assisted to the bathroom by staff. Documentation further noted Employee 1 put Resident 3's medications on her bedside table when Resident 4 (resident in bed B) requested a pain pill, and she left the room to obtain the pain medication from the medication cart. When Employee 1 returned with the pain medication, Resident 4 had ingested the medications she put on Resident 3's bedside dresser. The registered nurse notified the on call provider and received a new order to check vital signs every shift for 24 hours. Nursing documentation dated October 26, 2024, at 3:52 PM noted the registered nurse supervisor was notified of Resident 4's most recent blood pressure reading of 74/34 mmHg (millimeters of mercury). The registered nurse was in the room and took a manual blood pressure with systolic (pressure in the arteries when the heart beats) pressure of 76 and she was unable to hear diastolic (pressure in the arteries when the heart is at rest between beats). Documentation revealed the on-call provider was notified immediately and the facility received a new order to send Resident 4 to the emergency department for further evaluation. Review of Resident 4's Minimum Data Set (an assessment completed at specific intervals to determine resident care needs) dated October 24, 2024, noted staff assessed Resident 4 as independent in his wheelchair. The assessment indicated that Resident 4's BIMS (Brief Interview for Mental Status, which indicates cognition) score was 15, which indicated he was cognitively intact. Review of facility documentation revealed Resident 4 took the following medications in error: Amlodipine (medication to treat high blood pressure) 10 milligram (mg), one tablet Ferrous Sulfate (iron supplement) 325 mg, one tablet Lisinopril (medication used to treat high blood pressure) 20 mg, two tablets Magnesium Oxide (medication to treat heart burn) 400 mg, one tablet Page 1 of 2 395767 395767 10/30/2024 Rose View Rehab and Care Center 1201 Rural Avenue Williamsport, PA 17701

F 0760 Risperdal (antipsychotic medication) 0.5 mg, one tablet Level of Harm - Minimal harm or potential for actual harm Amitriptyline (antidepression medication) 10 mg, two tablets Baclofen (muscle relaxant) 5 mg, one tablet Residents Affected - Few Benztropine Mesylate (medication to treat tremors) 0.5 mg, two tablets Carvedilol (medication used to treat high blood pressure) 25 mg, one tablet Famotidine (medication to treat heart burn) 20 mg, one tablet Metformin (antidiabetic medication) 1000 mg, one tablet Review of hospital documentation dated October 26, 2024, revealed Resident 4 presented to the emergency department for hypotension (low blood pressure) and altered mental state secondary to accidental medication administration. Resident 4 was treated with intravenous fluids and observed in the emergency department for four hours. Further review of Resident 4's clinical record revealed nursing documentation dated October 27, 2024, at 12:29 AM noting Resident 4 was hypotensive again so on call provider was called and ordered intravenous fluids. Attempts to gain intravenous access was unsuccessful, and Resident 4's blood pressure was rechecked and was 104/59 mmHg. The physician was notified and ordered a subcutaneous button (a small needle inserted into the fatty tissue beneath the skin) access for fluids. Documentation revealed access was obtained and fluids running. During an interview with Employee 1 on October 30, 2024, at 12:05 PM confirmed she left Resident 3's medications unattended on her bedside table while Resident 3 was in the bathroom. Employee 1 stated she left the room to obtain a pain pill for Resident 4 and when she reentered the room, she noticed that Resident 4 had taken all Resident 3's medications. Employee 1 confirmed Resident 4 is independent in his wheelchair and able to wheel himself in the room. The facility failed to ensure that Resident 4 was free of a significant medication error. 28 Pa Code:211.12(d)(1)(2)(5) Nursing Services 395767 Page 2 of 2