Aviata At North Florida

During an interview on 10/09/2025 at 10:37 AM the Administrator stated, Nurses are educated in orientation regarding medication administration and the associated processes, including ordering medications and equipment from the pharmacy.

The expectation was that when a resident was admitted their medication orders were sent to the pharmacy.

The facility had previously had issues regarding medication availability and administration, and it was a topic they all focused on.

The process with the pharmacy was to deliver the medications and any equipment on their next run. If medication was not available from the pharmacy, the nurses had access to the [name of automated medication dispensing machine] and the pharmacy was able to get medications from a sister pharmacy if necessary.

During an interview on 10/10/2025 at 2:06 PM with the DON when asked regarding the significant medication errors related to the administration of vancomycin and cefepime for Resident #1 the DON stated, I am new to the facility. I wasn't here when this hap

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Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

patency, prevent mixing of incompatible medications and solutions; and to ensure entire dose of

catheter for blood to confirm patency prior to administration of medications and solutions.

Procedure:

• Flush with normal saline (amount established by pharmacy of facility protocol) using push-pause

method.

Review of the policy and procedure titled Catheter Insertion and Care: Central Venous Catheter Dressing Changes with an effective date of 1/17/2019 and the last approval date of 2/7/2025 read, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.

General Guidelines: 2.

Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet, soiled, or not intact).

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Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

During an interview on 10/10/2025 at 2:06 PM with the DON when asked regarding the significant medication errors related to the administration of vancomycin and cefepime for Resident #1 the DON stated, I am new to the facility. I wasn't here when this happened.2) Review of Resident #3's admission record documented the resident was admitted on [DATE] with diagnoses to include acute osteomyelitis, left ankle and foot, orthopedic aftercare following surgical amputation, type 2 diabetes, acquired absence of left leg below knee, acquired absence of other left toes, and unspecified sequelae of cerebral infraction.Review of Resident #3 physician order dated 10/3/2025 read, IVs: Flush Midline with 10cc of normal saline every shift and as needed.

Review of Resident #3 MAR for the month of October 2025 for IV Flush 10cc documented on 10/4/2025 and 10/5/2025 at 12 :00 (midnight) administered by Staff H, LPN.Review of Resident #3's physician order dated 10/4/2025 read, Linezolid [antibiotic used to treat serious bacterial infections] intravenous solution 600 mg/300 ml (Linezolid) Use 300 ml intravenously every 12 hours for skin/skin infection for 5 days 150 ml/hr [milliliter per hour].Review of Resident #3's MAR for the month of October 2025 for Linezolid Intravenous Solution 300 ml documented on 10/04/2025 at 2100 [9:00 PM] administer by Staff H, LPN, and on 10/5/2025 at 2100 administered by Staff H, LPN.Review of Resident #3's physician orders dated 10/2/2025 read, Zosyn [intravenous antibiotic combination piperacillin and tazobactam; a broad-spectrum antibiotic used to treat moderate-to-severe bacterial infections] intravenous solution 3-0.375 gm/50 ml (3 grams of piperacillin and 0.375 grams of the beta-lactamase inhibitor tazobactam in De

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Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

medications for 1 of 3 residents reviewed for medication administration (Resident #2).Findings

unspecified organism, chronic obstructive pulmonary disease with acute exacerbation (an increase in the severity of an illness), acute and chronic respiratory failure with hypercapnia (high carbon dioxide levels in the blood), low back pain unspecified, cognitive communication deficit, other malaise, muscle weakness generalized, orthopnea (shortness of breath that occurs when lying down), dehydration, dependence on supplemental oxygen, hyperlipidemia unspecified (high cholesterol), essential primary hypertension (high blood pressure), and hypercalcemia (high calcium levels in the blood).Review of Resident #2's physician order dated 4/25/2025 read, Metoprolol Tartare Oral Tablet 25 mg [milligram] (Metoprolol Tartare), give 0.5 tablet by mouth two times a day for HTN [hypertension].

Hold for SBP [Systolic Blood Pressure] < [less than] 110 or HR [heart rate] <70.Review of Resident #2's Medication Administration Record (MAR) for April 2025 documented Metoprolol was administered on 4/28/2025 at 0900 (9:00 AM) with a blood pressure (B/P) of 107/72, on 4/28/2025 at 2100 (9:00 PM) with a B/P of 101/68.Review of Resident #2's MAR for May 2025 documented Metoprolol was administered at 0900 on 5/12/2025 with a B/P of 102/77, on 5/16/2025 with a B/P of 109/58, on 5/24/2025 with a B/P of 101/64, on 5/30/2025 with a B/P of 100/57 and at 2100 on 5/8/2025 with a B/P of 98/62, on 5/13/2025 with a B/P of 106/67, on 5/22/2025 with a B/P of 98/64, and on 5/23/2025 with a B/P of 102/62.Review of Resident #2's MAR for June 2025 documented Metoprolol was administered at 0900 on 6/1/2025 with a B/P of 106/54, on 6/2/2025 with a B/P of 102/65, and on 6/16/2025 with a B/P of 96/52, and at 2100 on 6/5/2025 with a B/P of 98/63, on 6/14/2025 with a B/P of 107/82, and on 6/15/2025 with a B/P of 80/48.

During an interview on 10/7/2025 at 1:00 PM, Staff A, Licensed Practical Nurse (LPN), stated, I'm not sure if I gave the medication, but I will usually put in that I held it, my initials mean it was given. We should follow orders and not administer medications outside parameters.

During an interview on 10/7/2025 at 1:53 PM, Staff B, LPN, stated, I was not told that he [Resident #2] had any hypotension [low blood pressure] the night before. I would not have given his blood pressure medications. I would have held them. I can't remember if there were parameters for the medication.

During an interview on 10/7/2025 at 3:10 PM, the Director of Nursing (DON) stated, I was not here during that time. I was not aware of any concerns related to his [Resident #2] care.

All staff should administer medications as they are ordered and call the doctor or nurse practitioner if there is any change in vital signs.During a telephone interview on 10/7/2025 at 3:55 PM, Staff J, LPN, stated, I must have given it if I didn't document that I held the medicine. I don't really know, but if I documented I gave it I must have. We should follow the parameters if a medicine has them.

During an interview on 10/8/2025 at 8:51 AM, the Advanced Practice Registered Nurse (APRN) #1 stated, I would not expect the staff to administer blood pressure medications outside the parameters.During a telephone interview on 10/8/2025 at 9:58 AM, the Medical Doctor (MD) stated, The staff should follow all orders with parameters and not administer them [medications] outside of those. I was not notified of this.

During an interview on 10/8/2025 at 10:27 AM, Staff L, LPN, stated, I did give the medication [Metoprolol]. I'm not sure why I didn't hold it.

Review of the policy and procedure titled Administering Medications with the last review date of 02/07/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.

Policy Interpretation and Implementation. 2.

The Director of Nursing Services supervises and directs all personnel who administer medication and/or have related functions. 4.

Medications are administered in accordance with prescriber orders, including any required time frame.

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Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

emergency stock is utilized ensure that the pharmacy received the faxed information (i.e., customer

jeopardy to resident health or normal pharmacy hours: 1. A licensed nurse obtains the ordered medication from the emergency stock safety supply. 2. If the ordered medication is unavailable in the emergency stock supply, a licensed nurse calls the pharmacy's emergency answering service and request to speak with a registered pharmacist

emergency (backup) pharmacy. D. If an emergency delivery is not feasible, a licensed nurse contacts the attending physician to obtain orders or directions which may include: 1.

Holding the dose/doses.

• Use of alternative medication available from the emergency stock supply. 3.

Change in order (time of administration or medication). F.

When a missed dose is unavoidable: 1.

Document missed dose on the medication administration record (MAR) or treatment administration record (TAR): a.

Initial and circle to indicate any missed dose document explanation for missed dose according to physician's order: e.g. hold dose on back of MAR/TAR and indicate See nurses note for explanation. 2.

Document explanation of missed dose in the nurses' notes: a.

Describe circumstances of medication shortage. B.

Notification of pharmacy and response.

Review of the facility policy and procedure titled Administering Medications with a last review date of 02/07/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.

Policy Interpretation and Implementation. 2.

The Director of Nursing Services supervises and directs all personnel who administer medication and/or have related functions. 4.

Medications are administered in accordance with prescriber orders, including any required time frame. 5.

Medication administration times are determined by resident need and benefit, not staff convenience.

Factors that are considered include: a.

Enhancing optimal therapeutic effect of the medication. 6.

Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.

Review of the policy and procedure titled, 1.0 Providing Pharmacy Services, with the last review date of 02/07/2025 read, Policy: [Name of Pharmacy Provider] will: Provide a continuum of pharmaceutical services to the facility and essential medication and services for the customers.

Ensure that the facility staff has access to medications, emergency service for medications, and drug information on a twenty-four (24) hour basis.

Procedure: A. [Name of Pharmacy Provider] provides the facility with details how the customer can contact [Name of Pharmacy Provider] twenty-four (24) hours a day, seven (7) days a week. D. If orders for medication are received from the physician the facility may: 1. A delay in medication therapy can be prevented by using a drug that is included in the facility's Back-up Box/stat/emergency kit drug supply [located in the [name of the automated medication dispensing machine]. 3. If a drug is considered essential and cannot be substituted or delayed, please contact the [Name of Pharmacy Provider] Emergency Number.

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Aviata at North Florida 6700 NW 10th Place Gainesville, FL 32605

Review of Resident #1's Medication Administration Record for the month of September 2025 for

midnight and a chart code of 9 at 0800 [8:00 AM] and 1600 (4:00 PM). On 9/11/2025 a chart code of H

Resident #1's MAR for cefepime dated 09/9/2025 at 6:00 AM documented a code of 5 (Hold/see Nurses Notes) and 1400 (2:00 PM) a code of 9 (Other/See Nurses Notes).

For a total of two missed doses.

During an interview on 10/07/2025 at 1:36 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #1's name] had been transferred from another room during my shift [9/9/2025]. [Name of Staff B] had [Resident #1's name] prior to me and had called pharmacy who said they would be bringing his medication [vancomycin]. I called the pharmacy again and the pharmacy said they were enroute with the medication. I called the nurse practitioner; I believe her name is [APRN #1's name].

She [APRN #1] told me to extend the order for vancomycin for an extra day, so [Resident #1's name] would have the full course of the antibiotics.

The pharmacy courier came in around 7:05 [PM] and brought me his medications. I passed them on to the night shift nurse because it was getting late. I don't think I wrote a note because I was in a rush to leave. I believe I should have documented the conversation with [name of APRN #1].

During an interview on 10/07/2025 at 1:38 PM, Staff B, LPN stated, [Resident #1's name] was an admission from the day before [9/8/2025].

The night-shift nurse [Staff E, LPN] told me that the nurse who admitted the resident did not put in [Resident #1's name] medication orders, so [Staff E's name] was not able to administer any medications for him. I can't remember if she called a provider, but I thought she had gotten an order to hold the vancomycin. If the medication was available in the [name of the automated medication dispensing machine] it should be administered. I know I should have notified the provider of the missed medications, and I should have documented the notification and any orders or instructions from the provider. I'm not sure if we can do a stat order from the pharmacy, we just regularly call the pharmacy and tell them we are waiting for the medication.

During an interview on 10/07/2025 at 3:20 PM Staff E, LPN stated, Most of [Resident #1's name] medications were not available on the night shift of 9/8/25 - 9/9/25.

The pharmacy doesn't come to the facility until 6:00 AM.

Medication orders are typically entered to start the following day [after admission] because of the delivery times from the pharmacy, but [Resident #1's name] medications were ordered to start on the day of his admission [DATE]].

For the medications that were scheduled for my shift I was able to administer his cefepime because it was available in the [name of automated medication dispensing machine].

There was not a dose of vancomycin in the [name of automated medication dispensing machine] but there was overflow of vancomycin in the med [medication] room, as well as an overflow pump, so I was able to administer the ordered dose of vancomycin. I was not able to administer the morning dose of cefepime. I might have notified the doctor that I could not give the cefepime, but I am not sure. I did notify management that I did not give the cefepime, but I did not document the notification because I was already off of the [medication] cart. I know I should have written a note.

Review of the policy and procedure titled Catheter Insertion and Care with an effective date of 1/17/2019 and the last approval date of 2/7/2025 read, Documentation: The following information should be recorded in the resident's medical record: 1.

The date and time of the procedure. 2.

The number of venipuncture attempts (maximum of two). 3.

The type, length and gauge of the catheter, and type of cleansing agent used. 4.

The site of insertion (be specific to name of vein, area of arm). 5.

The type of solution used or medication infusing (if being used at this time). 10.

Resident's response to the procedure. 11.

The signature and title of the person recording the data.