Mercy's Carehome II

Based on record review and interview, the manager failed to ensure documentation of medication administered to the resident included the dosage for one of two residents sampled. The deficient practice posed a risk as medication administration could not be verified against a medication order. Findings include: 1. A review of R2's medical record revealed a medication order dated May 15, 2025 for "Insulin Aspart 100 U/ML P inject subcutaneously per sliding scale: 0-60 - 0, 61-150 - OU, 151-200 - 4U, 201-250 - 6U, 251-300 - 8U, 301-350 - 10U, 351-400 - 15U, More than 401 and above - CALL MD." 2 . A review of R2's medication administration record (MAR) revealed "Insulin Aspart 100 U/ML P, inject subcutaneously before meals and at bedtime per sliding scales: 61-150 = OU, 151-200 = 4U, 201-250 = 6U, 251-300 = 8U, 301-350 = 10U, 351-400 = 15U, More than 401 = 15U, CALL MD, see chart." The MAR did not include documentation of the dosage of Insulin Aspart 100 U/ML P administered to R2. 3. A review of R2's medical record revealed blood glucose logs for August and September 2025 that did not include documentation of the dosage of Insulin Aspart 100 U/ML P administered to R2. 4 . In an interview, E1 reported that insulin was administered to R2, but the dosage was not documented. 5. In an exit interview, findings were discussed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure that medication was stored in a separate locked, self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. During an environmental inspection, the Compliance Officers observed R2's Insulin Aspart 100 U/ML Pen medication stored unlocked on the inside door of the refrigerator located in the facility's kitchen. 2. During an environmental inspection, the Compliance Officers observed maximum strength Tussin and Chest Congestion medication syrups stored unlocked on the inside door of the refrigerator located in the facility's kitchen. 3. In an exit interview, findings were discussed with E1 and no additional information was provided.