Health inspection·October 2, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide care to a resident who had not received scheduled medication for one of four residents (Resident R1). Residents Affected - Few Findings include: Review of the facility policy Medication Administration dated May 2024, indicated the facility will administer all medications consistent with standard of care and prescribed by the physician/designee. Review of the facility policy Medication Incident Report dated May 2024, indicated the physician will be notified of a medication error and recommendations will be received. Review of the clinical record indicated Resident R1 was readmitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/22/24, included diagnoses of malnutrition (lack of sufficient nutrients in the body) and orthostatic hypotension (a sudden drop in blood pressure upon standing from a sitting or lying position). Review of Section C: Cognitive Patterns indicated Resident R1 had moderate cognitive impairment. Review of the facility diagnosis list included diagnoses of high blood pressure and paroxysmal atrial fibrillation (a type of irregular heartbeat that resolves on its own or with treatment). Review of Resident R1's blood pressure record for August 2024 revealed one assessment completed on 8/1/24. Review of Resident R1's Medication Administration Record (MAR) indicated that on 8/9/24, Registered Nurse (RN) Employee E1 documented that the following scheduled medications (scheduled at 9:00 a.m.) were provded: -2.5 milligrams (mg) Eliquis (medication to prevent blood clot formation). -2 mg Immodium (medication to treat diarrhea). -10 milliequivalents (mEq) Klor-Con (potassium supplement). -5 mg Midodrine (medication to treat orthostatic hypotension). Page 1 of 2 396124 396124 10/02/2024 Providence Point Healthcare Residence 200 Adams Ave Pittsburgh, PA 15243

F 0684 -80 mg Sotalol (medication to treat an irregular heart beat). Level of Harm - Minimal harm or potential for actual harm Review of a facility provided handwritten, Medication Error Report dated 8/9/24, at 4:00 p.m. indicated, All 9am medications in med cart at 4 pm. I asked [RN Employee E1] if there was a reason meds not given. No reply other than Let me see I gave them. Shown [RN Employee E1] the packets. Residents Affected - Few Review of the Physician Notification and Action Taken section of the above report failed to reveal documentation that the provider was notified of the omission of medication. Review of the Safety Events - Medication Error report documented in the electronic medical record dated 8/9/24, at 7:10 p.m. indicated, no medications given found packets in med cart, all medications signed off in MAR as given. The report further indicated, I ask [RN Employee E1] if there was a reason [Resident R1] did not get her morning meds, [RN Employee E1] just stated let me see the package I gave them I showed her the package she wanted to take it to throw away. Review of the Notifications section of the above report revealed Physician notified entry documented as No, and the resident representative entry documented as No. Review of Resident R1's progress notes revealed a progress note completed on 8/2/24, with no further notes documented until 8/15/24. During an interview on 10/2/24, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that there was not documentation in the medical record to indicate Resident R1 had vital signs completed or assessed for possible ill-effects after not receiving medications, specifically medications to regulate her heart rate and blood pressure, and further confirmed that the medical provider was not notified of Resident R1 not receiving her medications. During an interview on 10/2/24, at approximately 1:30 p.m. the Nursing Home Administrator confirmed that the facility failed to provide care to a resident who had not received scheduled medication for one of four residents. 28 Pa. Code: 201.18(b)(1) Management. 28 Pa. Code: 201.29(a) Resident rights. 28 Pa. Code: 201.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 396124 Page 2 of 2