**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review, review of POTTER and [NAME] FUNDAMENTALS OF NURSING and review of facility policies titled Medication - Adverse Consequences & (and) Medication Errors and Medication - Administration, the facility failed to ensure the medication pass administration conducted on 10/27/2022, was free of any significant errors. During the medication pass, Employee Identifier (EI), #2, an LPN (Licensed Practical Nurse) prepared and administered Resident Identifier (RI) #5's medications to RI #1. This deficient practice affected RI #1, one of four residents sampled for medication administration. Findings Include: A facility policy titled Medication - Adverse Consequences & (and) Medication Errors, with a revised date of 08/01/2015, revealed the following: . Procedure . 4. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufactures specifications, or accepted professional standards and principles of the professional(s) providing services. Responsibility The Charge Nurse is responsible for the implementation of this policy and procedure . Pages 624 - 627 of Chapter 32 titled Medication Administration of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of 2017, revealed: . Medication Errors A medication error can cause or lead to inappropriate medication use or patient harm. Medication errors include . administering the wrong medication, . Preventing medication errors is essential . Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors . When an error occurs, the patient's safety and well-being are the top priorities. You first assess and examine the patient's condition and notify the health care provider of the incident as soon as possible . Steps to Take to Prevent Medication Errors . * Follow the six rights of medication administration . Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation . Right Patient. Medication errors often occur because a patient gets a drug intended for another patient. Therefore an important step in safe medication administration is being sure that you give the right medication to the right patient . Another facility policy titled Medication - Administration, with a revised date of 03/22/2022, revealed the following: Purpose Medications shall be administered . as prescribed by the resident's attending physician or the facility' Health Care Practitioner. Policy Medications shall be given as ordered by the physician. Procedure . 2. Medications shall be administered . in accordance with the physician's written/verbal orders . On review of EI #2's LPN Orientation Checklist with a hire date of 08/15/2022, EI #2 reviewed and performed the facility's Medication system and identification system for residents on 08/18. RI #1 was admitted to the facility on [DATE] with diagnoses to include Hypertensive Heart Disease without Heart Failure, Anxiety Disorder, Chronic Atrial Fibrillation and Cognitive Communication Deficit. RI #1's November 2022 Physician Orders included Plavix 75 mg (milligrams) and Norvasc 5 mg daily for the Hypertensive Heart Disease, Zoloft 100 mg daily for the Anxiety and Amiodarone HCL (Hydrochloric Acid) 200 mg one half tablet to equal 100 mg daily for the Chronic Atrial Fibrillation. RI #5 was admitted to the facility on [DATE] with diagnoses to include Essential Hypertension, Unspecified Pain, Mood Disorder, Anemia, Vitamin D Deficiency, Anxiety Disorder and Acute Embolism and Thrombosis. RI #5's November 2022 Physician Orders included Atenolol 25 mg, Amlodipine (Norvasc) 10 mg, Lisinopril 10 mg daily for the Essential Hypertension, Neurontin 300 mg daily for the Unspecified Pain, Venlafaxine HCL ER ( Effexor) 150 mg daily for the Mood Disorder, Iron 325 mg every day for the Anemia, Vitamin D3 1,000 units give two tablets to equal 2,000 units daily for the Vitamin D Deficiency, Ativan 0.5 mg give half tablet to equal 0.25 mg daily for the Anxiety Disorder, Eliquis 5 mg twice a day for the Acute Embolism and Thrombosis, Norco 5-325 one by mouth twice a day for Pain and Saline 0.65% Nasal Spray one spray to each nostril twice a day. RI #1's Departmental Note (Nurses Note) dated 10/27/2022 at 12:50 PM, revealed the following: . Medication error occurred at 10:15AM the Charge Nurse gave resident another resident's morning medications. Resident received Neurontin 100mg, Amlodipine 10mg, Lisinopril 10mg, Effexor 150mg, Atenolol 25mg, Iron 325mg, Vitamin D3 1000 units, Ativan 0.5mg, Norco 5mg, Eliquis 5mg, Sodium CL Nasal spray. Resident is alert . with periods of confusion. Resident denies pain or discomfort. Vital signs are BP (Blood Pressure) 122/66 Pulse 74 Resp 18 Temp (Temperature) 97.7 02 Sat (saturation) 936% on RA (Room Air) . Pharm D was in facility and was made aware. (Name of CRNP [Certified Registered Nurse Practitioner]) was made aware with new orders for Q (every) 15min vital signs, monitor heart rate due to Afib and watch for sedation, hold (his/her) scheduled morning medications today, Bactroban apply to bilateral nares for preventive measures. Body Audit was performed to monitor for any adverse reaction to blood thinner . Resident and representative (name of representative) was made aware . Addendum 10/28/2022 11:07 AM clarification sat 93% on RA . A review of RI #1's Medication Error Report dated 10/27/2022, documented: MEDICATION ERROR: Nurse gave the resident another residents morning medications Neurontin 300 mg, Amlodipine 10mg, Lisinopril 10mg, Effexor 150mg, Atenolol 25mg, Iron 325mg, Vitamin D3 1000 units, Ativan 0.5mg, Eliquis 5mg, Sodium CL nasal spray. ACTION TAKEN: Vital signs, assessments, notified Pharm D, (name of CRNP), (name of representative), orders to hold res (resident's) scheduled morning meds, give Bactroban ointment to nares as preventive measures, vital signs every 15 minutes, watch for sedation . RI #1's Departmental Notes revealed the following: . 10/28/2022 11:08 AM . late note for 10/27/2022 4pm. Update given to (name of representative). Resident remains alert with no sedation noted. Resident did take a nap after lunch. Vitals signs are stable. No respiratory distress noted. 10/28/2022 11:14 AM . Vital signs are stable. Resident is alert with periods of confusion at current baseline. Blood pressures have returned to normal limits and no other side effects or adverse reaction noted at this time . 10/28/2022 6:58 PM . B/P 128/76 P (Pulse) 76 R (Respirations) 18 T (Temperature) 97.7 and 02 sat 98% . On 11/09/2022 at 11:44 AM, the surveyor conducted a telephone interview with EI #2, the LPN administering RI #1 the wrong medications on 10/27/2022. The surveyor asked EI #2 what process she used when she prepared to administer RI #1 his/her medications. EI #2 said this was the first day she was by herself. EI #2 said the Internet was down on one end of the hall so after she pulled up the medications for RI #5 she walked the medications to RI #1's room. When asked how was it that RI #1 was administered the wrong medications, EI #2 said she pulled up RI #5's medications and went to RI #1's room and said, RI #5 here are your medications. EI #2 said RI #1 responded to RI #5's name so she thought RI #1 was RI #5. EI #2 said as soon as she stepped out the door, she realized the resident was RI #1 and not RI #5. When asked who she informed when she realized she had administered RI #1 the wrong medications, EI #2 said she asked someone to get EI #1, the Director of Nursing (DON). EI #2 said she did vital signs all day long on RI #1. EI #2 said the doctor was informed of the medication error and the pharmacy. The surveyor asked EI #2 was she in-serviced on how to pass medications after the incident. EI #2 said she got an in-service from RI #1 and the pharmacist, EI #3 told her to pay close attention and follow the protocols for administering medications. When asked what she was taught in orientation about administering medications to the residents, EI #2 said she believe the six rights of administering medications were gone over. When asked what are the six rights of administering medications, EI #2 said before you administer medication make sure you have the right resident, right medication, the right dose, it was the right time, and you are giving it the right way. The surveyor asked EI #2 why did she not follow that procedure when she administered RI medications on 10/27/2022, EI #2 said she thought she just did not pay enough attention to what she was doing. On 11/10/2022 at 9:36 AM, the surveyor conducted an interview with EI #3, the Pharmacist. EI #3 said he was at the facility the day the medication error occurred. EI #3 said after the incident occurred RI #1 did not appear to be overly sedated, hypotensive, and did not appear to be in any type of distress. When asked what kind of side effects a person would experience from taking the medication Neurontin, EI #3 said one of the major ones would be SOB (shortness of breath) and sedation. When asked what kind of side effects a person would experience from taking the medication Amlodipine, EI #3 said you would think about lower blood pressure, so hypotension. When asked what kind of side effects a person would experience from taking the medication Lisinopril, EI #3 said you would think about lower blood pressure, so hypotension. When asked what kind of side effects a person would experience from taking the medication Effexor, EI #3 said that one may raise the blood pressure a little bit. When asked what kind of side effects a person would experience from taking the medication Atenolol, EI #3 said you would think about lower blood pressure, so hypotension and it would also lower the heart rate. When asked what kind of side effects a person would experience from taking the medication Iron, EI #3 said constipation, but you would not see that with taking one dose. When asked what kind of side effects a person would experience from taking the medication Vitamin D3 1,000 units, EI #3 said from one dose probably nothing; but it can cause GI upset. When asked what kind of side effects a person would experience from taking the medication Ativan, EI #3 said you would see sedation. When asked what kind of side effects a person would experience from taking the medication Eliquis , EI #3 said you would probably experience bleeding over a period of time. When asked what kind of side effects a person would experience from taking the Sodium Cl Nasal spray, EI #3 said none. The surveyor asked EI #3 did the facility report to him RI #1 experienced any of those side effects. EI #3 said RI #1's BP was low a few times, but RI #1 did not have any symptoms from that. When asked what is there a potential for when a resident was given medications that are not prescribed for them, EI #3 said for one it would fall into a medication error category. EI #3 said situations like this could fall into adverse drug reaction or adverse drug event. The surveyor asked EI #3 were RI #1's Physician Orders followed that morning when RI #1 received someone else's medications. EI #3 said no. EI #3 said he was able to speak with EI #2 to get to the bottom of what caused the error. When asked what caused the error, EI #3 said EI #2 informed him when she walked into the room RI #1 responded to RI #5's name so she proceeded to administer the medications. EI #3 said he reminded EI #2 there were pictures of the residents on the electronic MAR so be sure to look at the resident's picture and always have the medication cart by the resident's room. On 11/10/2022 at 10:46 AM, the surveyor conducted an interview with EI #4, the CRNP. EI #4 said she was called by EI #1 and EI #1 gave her the names of all the medications that had been administered to RI #1. EI #4 said EI #1 had done a body audit on RI #1 and did not see any changes. EI #4 said she told EI #1 to watch for the resident's BP (blood pressure) dropping, for decreased respirations, increased confusion, lethargic and any kind of anaphylactic symptoms, like difficulty swallowing or slurred speech. EI #4 said she informed EI #1 RI #1's BP would probably get low and to notify her if it did. EI #4 said she was informed it had dropped but it came back up. EI #4 said when she observed RI #1, RI #1 was in bed and was alert and awake. EI #4 said she asked RI #1 if his/her heart felt funny and if he/she had trouble breathing and RI #1 said no he/she felt fine. EI #4 said she informed RI #1 he/she was given medications that he/she was not prescribed, and RI #1 said he/she felt fine. The surveyor asked EI #4 what was there a potential for when a resident was given medications that are not prescribed for them. EI #4 said an allergic reaction and possible side effects. When asked were RI #1's Physician Orders followed when RI #1 received someone else's medications, EI #4 said no. On 11/10/2022 at 2:07 PM, the surveyor conducted an interview with the DON, EI #1. EI #1 said when she was made aware EI #2 had administered RI #1 RI #5's medications, she informed her staff to go ahead and get RI #1's vitals and informed them they would have to do them every 15 minutes. EI #1 said she called EI #4, the CRNP and EI #3, the pharmacist was at the facility and was informed RI #1 had gotten a lot of medicines that were not his/her own and a med error had occurred. EI #1 said she got a list of RI #5's medication and when she got on the phone with EI #4 she (EI #1) went over what RI #1 received and what RI #1 was supposed to have gotten. EI #1 said she informed EI #4 they were monitoring RI #1's vitals every 15 minutes and EI #4 told her to continue to do that and they discussed what to be looking for. When asked did EI #2 say what happened, EI #1 said EI #2 just said she got the two residents confused and that they kind of looked alike. EI #1 said when EI #2 went in and said, RI #5 I have your medications, RI #1 said Ok and she gave them to RI #1. EI #1 said EI #2 said when she got back to the computer was when she realized she had given the wrong medications. The surveyor asked were the physicians ordered followed when EI #2 administered RI #1 someone else's medications. EI #1 said no. When asked which of the medications would be considered significant medication, EI #1 said the narcotics, the beta blocker, and the blood thinners. This deficiency was cited as a result of the investigation of complaint/report #AL00042168.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and a facility policy titled, Handwashing-Hand Hygiene, the facility failed to ensure a licensed nurse washed her hands after removing gloves, prior to administering a topical medication to Resident Identifier (RI) #33. This affected one of three licensed nurses observed during medication administration pass and RI #33, one of four residents observed during medication administration pass. Findings Include: RI #33 was admitted to the facility on [DATE] with the diagnosis of Dry eye syndrome of unspecified lacrimal gland, Generalized pain, and Unspecified Osteoarthritis. A review of a facility policy titled, Handwashing-Hand Hygiene with a revised date of 03/01/2017, revealed Handwashing-Hand Hygiene Purpose To prevent the spread of infection . 5. Employees must wash their hands . under the following conditions: . u. After removing gloves . 8. The use of gloves does not replace handwashing/hand hygiene. On 3/20/19 at 8:51 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), during a medication administration pass for RI #33. The surveyor observed EI #1 remove her gloves after giving an eye drop medication to RI #33. EI #1 then removed her gloves and put on another pair of gloves to apply a tropical cream to RI #3's neck. EI #1 did not wash her hands prior to putting on the other pair of gloves. On 3/20/19 at 1:58 p.m., an interview was conducted with EI #1. She was asked did she wash her hands after removing her gloves, and prior to putting on another pair of gloves before applying a topical cream on RI #33's neck. EI #1 stated no. EI #1 was asked why she did not wash her hands after removing her gloves and prior to putting on another pair of gloves before applying the cream on RI #33's neck. EI #1 stated she just forgot to wash her hands. EI #1 was asked what was the facility policy on hand hygiene after removing gloves when giving medications to a resident. EI #1 replied that you should wash your hands after removing gloves. EI #1 was asked what would be the concern in not washing her hands after removing gloves prior to giving a resident a topical medication. EI #1 stated it could cause contamination or infection to a resident. On 3/20/19 at 2:03 p.m., an interview was conducted with EI #2, Registered Nurse/Infection Control Preventionist. EI #2 was asked what was the facility policy regarding hand hygiene after removing gloves when giving medications to a resident. EI #2 stated you should always wash your hands or use hand sanitizer. EI #2 was asked what would be the concern with not washing your hands after removing gloves prior to giving a resident a topical medication. EI #2 stated it could cause cross contamination and could cause an infection to the resident.