**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of Resident Identifier (RI) #14's and RI #43's medical records, FUNDAMENTALS OF NURSING NINTH EDITION, the MEDICATION ERROR REPORT, Employee Identifier (EI) #1's EMPLOYEE STATEMENT FORM and a complaint received by the Alabama State Survey Agency, the facility failed to ensure EI #1, a Licensed Practical Nurse (LPN) administered medications to RI #43 in accordance with accepted standards of practice and the physician's orders. The Alabama State Survey Agency received a complaint which alleged, the nursing staff administered the wrong medications to RI #43. According to the complainant, RI #43 tested positive for medications of which the resident was not ordered to receive. During the 9:00 AM medication pass on 10/29/2019, EI #1, an LPN prepared medications for RI #14. As the LPN entered RI #14's room to administer the medications, she noticed RI #14 was not in the room; the resident was in the shower room. EI #1 placed the unlabeled cup of medications in the drawer of the medication cart. EI #1 then prepared RI #43's medications for administration. As the LPN entered RI #43's room, she noticed the resident was not in the room; the resident was in the shower room. The LPN then walked to the medication cart and placed another unlabeled cup of medications in the top drawer of the medication cart. When both residents were available, the LPN removed the medication cups from the drawer and administered the medications to each of the residents, without verifying the right medications and the right resident. RI #43 was administered medications to include: Baclofen, Tegretol, Clonidine, Valium, Naltrexone and Risperdal. RI #43 then left the facility via ambulance transport for a planned procedure at the hospital. When RI #43 arrived in the hospital's Emergency Room, the resident was noted to have a slow heart rate, slow breathing, and a low blood pressure. The resident was difficult to arouse with no spontaneous movement even to pain or sternal rub. RI #43 was admitted to the Pediatric Intensive Care Unit (PICU) due to the concern for serious illness in the setting of his/her altered mental status, risk of respiratory failure and other comorbidities. A urine drug screen was done on 10/29/2019, and it revealed RI #43 had medications in his/her system that were not ordered for the resident. After RI #43 was readmitted to the facility, EI #1, the LPN informed the facility's administrative staff, 13 days later, that she had administered medications that belonged to RI #14 to RI #43 on 10/29/2019. This deficient practice affected and placed RI #43, one of six residents receiving medication from the medication cart assigned to EI #1 on 10/29/2019 in immediate jeopardy as this failure was likely to cause serious injury, harm, impairment or death. On 12/14/2019 at 10:33 AM, the Administrator and Director of Nursing were notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Pharmacy Services/Residents Are Free of Significant Med Errors, F 760. Findings include: Pages 624 - 627 of Chapter 32 titled Medication Administration of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of 2017, documented . 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 . When you have made an error, reflect on what went wrong and ask how you could have prevented the error. Complete an occurrence report per agency policy . Ensure that you are well rested when caring for patients. Nurses make more errors when they are tired . Standards are actions that ensure safe nursing practice. Standards for medication administration are set by health care agencies and the nursing profession . To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. 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 . On 12/6/2019, the Alabama State Survey Agency received a complaint which alleged, the nursing staff administered the wrong medications to RI #43. According to the complainant, RI #43 tested positive for medications of which the resident was not ordered to receive. RI #14 was admitted to the facility on [DATE] with an admitting diagnosis of Cerebral Palsy. RI #14 has a medical history to include diagnoses of: Restlessness and agitation and other conduct disorders. RI #43 was admitted to the facility on [DATE]. RI #43 has a medical history to include diagnoses of: Congenital Myopathy, Tracheotomy, Spastic Quadriplegic Cerebral Palsy, and Epilepsy. On 12/11/2019 at 9:21 AM, a telephone interview was conducted with the Pediatric Intensive Care Unit (PICU) Social Worker (SW) at the hospital RI #43 was transferred to on 10/29/2019. The SW stated the emergency room (ER) staff knew RI #43 well and realized he/she was not acting like his/her normal self and ordered a drug screen test. According to the SW, RI #43 had come to the ER to have his/her feeding tube replaced. The SW stated two urine drug screens were done in the ER and a comprehensive drug analysis was sent to an outside facility; all of which came back positive. The SW stated the physicians at the hospital were concerned for RI #43 because the resident was not prescribed any of the medications in which he/she tested positive for. RI #43 was admitted to the hospital with Altered Mental Status (AMS). The SW stated on 10/29/2019 she called the nursing facility and spoke with RI #43's nurse, later identified as EI #1, an LPN. According to the SW, RI #43's nurse listed the medications RI #43 was administered but none of them were the ones the resident had tested positive for. On 12/11/2019 at 2:34 PM, an interview was conducted with EI #1, the LPN assigned to care for RI #43 during the 7:00 AM to 3:00 PM shift on 10/29/2019. When asked why RI #43 was being sent to the hospital, EI #1 stated because the resident's GJ (gastrostomy jejunostomy) tube was malfunctioning; it was leaking. When asked how medication was administered to RI #43, EI #1 replied, by way of the tube. EI #1 was asked if she administered medications to RI #43 on 10/29/2019. She replied, yes. EI #1 stated it was kind of a rush rush thing and she guessed this was how the mix up happened. When asked what mix up, EI #1 stated the medication for RI #14 was mixed up with RI #43's medications. EI #1 was asked what were RI #14's medications. EI #1 read from the Medication Administration Record (MAR): Vitamin D, Clonidine, Diazepam (Valium), Rantidine (Zantac), Risperdal, Naltrexone (Vivitrol), Aleve, Senexon, Baclofen, Carbamazepine (Tegretol) and Zanaflex. When asked how she thought the mix up occurred, EI #1 said she prepared RI #14's medications for administration; however, when she went to administer the medications to RI #14, the resident was in the shower. EI #1 stated she then put the medications in the medication cart. EI #1 then prepared RI #43's medications for administration. When EI #1 went to administer RI #43's his/her medications, the resident was also in the shower, so she placed RI #43's medication in the medication cart alongside RI #14's medications. EI #1 stated when the residents became available she administered each of the resident's their medications and got them mixed up. When asked if it was normal procedure to prepare medication for administration before seeing the resident, EI #1 said yes. EI #1 explained that if the resident was not available, the medication would be placed back into the medication cart and locked up. When asked how she would know who the medication belonged to, EI #1 answered, she would put the resident's name on the medication cup. EI #1 was asked if she did this on 10/29/2019 and she stated this was probably one of those mornings that she did not. When asked if RI #43 was administered RI #14's medications, EI #1 answered yes. EI #1 was asked when she realized that she had administered the wrong medications to RI #43. EI #1 replied, when the hospital called back to the nursing facility saying RI #43 was lethargic. When asked when she notified the facility's administrative staff of the error, EI #1 stated it was about a week and a half later. EI #1 explained that RI #43 had come back to the facility and it was being said that the resident was administered the wrong medications; that is when EI #1 informed the Administrator of the error she had made. According to EI #1, the Administrator asked her to come into the facility and talk with her and the Director of Nursing (DON). EI #1 stated she was suspended, and a medication error report was completed. The MEDICATION ERROR REPORT dated 11/11/2019 indicated on 10/29/2019 at 9:00 AM, RI #43 was administered medications not prescribed for him/her. The report documented . REASON FOR MAKING ERROR See Attached Nurse Statement COULD THIS ERROR HAVE ENDANGERED THE LIFE OR WELFARE OF THE RESIDENT? Yes . WHAT IS THE ACTUAL EFFECT OF THE ERROR MADE ON THE RESIDENT? Patient became over sedated. HOW WAS THE ERROR DISCOVERED? By drawing lab to discover why patient was so sedated. Nurse reported that she felt like she might have mixed medications up . WHAT PRECAUTIONS CAN BE TAKEN TO PREVENT A SIMILAR ERROR? . Only set up one resident medication @ (at) a time . EI #1's EMPLOYEE STATEMENT FORM dated 11/11/2019, documented The morning of the incident I didn't sleep well suffering from insomnia & had taken a bendryl (Benadryl) before coming in that morning, . I now (know) that day my judgement was impaired, I made mistake giving (RI #43) the wrong medication of another resident before (he/she) going (out) of the facility for a GJ tube replacement to the hospital . RI #14's PHYSICIAN'S ORDERS MEDICATIONS AND TREATMENTS for October 2019 revealed the resident was ordered the following medications at 9:00 AM: Ergocalciferol (Vitamin D2), used to treat a Vitamin D deficiency; Aleve, a non-steroidal anti-inflammatory; Senexon, used to treat constipation; Baclofen, used to treat muscle spasms; Carbamazepine (Tegretol), a medication used to treat seizures; Clonidine HCL, used to treat high blood pressure; Diazepam (Valium), a benzodiazepine used to treat anxiety, muscle spasms and seizures; Naltrexone (Vivitrol), used to prevent opiate effects; Ranitidine (Zantac), used to treat and prevent heartburn; Risperidone (Risperdal), an antipsychotic used to treat mental/mood disorders; and Tizanidine HCL (Zanaflex), used to treat spasticity. RI #43's PHYSICIAN'S ORDERS MEDICATIONS AND TREATMENTS for October 2019 revealed the resident was ordered the following medications at 9:00 AM: Prevacid, an over-the-counter medication used to treat heartburn; Poly-Vi-Sol, a multi-vitamin; Zyrtec, an antihistamine used to treat cold and allergy symptoms; Levetiracetam (Keppra), an anti-epileptic medication used to treat seizures in people with Epilepsy; and Culturelle, a probiotic used to improve digestion and restore normal flora. During an interview on 12/11/2019 at 3:37 PM, EI #4, the 7:00 AM to 3:00 PM shift Registered Nurse (RN) Supervisor was asked, what the standard of practice was nurses use when administering medications to a resident. EI #4 said make sure it is the right route, right dose, right time, right patient, right amount and the right medication. When asked how a nurse ensures this occurs, EI #4 replied, look at the resident's name, look at the medication and time, then pull the medications from the medication cart and prepare them for administration. When asked what a nurse should do if they have pulled (prepared) medications for administration and the resident was not available, EI #4 replied, first one should find out where the resident is before the medication is prepared. If the medication has been prepared and the resident is not in his or her room, have a Certified Nursing Assistant (CNA) find the resident and bring the resident to the room. If the resident is not available, the medication should be discarded. In an interview on 12/12/2019 at 3:11 PM, EI #2, the Administrator was asked, when EI #1, a LPN, administered the wrong medication to RI #43 on 10/29/2019, did it potentially endanger the life or welfare of the resident. EI #2 answered, yes. RI #43's hospital's History and Physical dated 10/29/2019, documented . Chief Complaint: HPI (History of Present Illness): (RI #43) . with history of congenital muscular dystrophy, . cerebral palsy, spastic quadriplegia, seizures, communicating hydrocephalus, chronic respiratory failure, trach and G tube dependence who presents today with G tube issues but found to be significantly altered . In the ED (Emergency Department), (RI #43) was noted to be bradycardic to the 90s, bradypneic with a rate of 8-10, with an initial blood pressure of 66/49 . (RI #43) was difficult to arouse and had no spontaneous movements even to pain or sternal rub . Once (RI #43) reached the floor, due to (his/her) positive drug screen, (he/she) was given two doses of 2 mg (milligram) naloxone with no response . A/P (Assessment/Plan): (RI #43) . presents with altered mental status secondary to suspected sepsis vs. medication polypharmacy vs overdose vs. subclinical seizures vs. meningitis vs. AKI (acute kidney injury). (RI #43) initial workup was reassuring against infection . We will plan to repeat UDS (urine drug screen) and send a comprehensive while attempting to obtain further information regarding these medications (neither are prescribed). (RI #43) remained admitted to the ICU (Intensive Care Unit) due to concern for serious illness in the setting of (his/her) altered mental status, risk of respiratory failure and (his/her) other comorbidities . RI #43's COMPREHENSIVE DRUG ANALYSIS, UR (Urine) with a 10/29/2019 date of service indicated the following drugs were present in RI #43's system: Desmethyldiazepam 648 Oxazepam 176 Temazepam 990 Desmethyldiazepam, oxazepam and temazepam are benzodiazepine drugs, but may also be present as common metabolites of other benzodiazepine drugs, including diazepam Naltrexone PRESENT Carbamazepine PRESENT Levetiracetam PRESENT Baclofen PRESENT Risperidone PRESENT Naproxen PRESENT Brompheniramine PRESENT . During an interview on 12/12/2019 at 12:13 PM, EI #8, the facility's Consultant Pharmacist was asked when she became aware that RI #43 had received the wrong medications. EI #8 replied, today (12/12/2019). When asked if she had the opportunity to review RI #43's COMPREHENSIVE DRUG ANALYSIS, UR, EI #8 said no. EI #8 was shown the results and asked what medication it stated Desmethyldiazepam, oxazepam and temazepam may be present as common metabolites of. EI #8 replied, Valium. When asked what that meant, EI #8 explained when Valium is taken the body breaks the medication down and it could show up in a drug screen as Desmethyldiazepam, Oxazepam and Temazepam. EI #8 was asked to review RI #14's ordered medications and asked which of the resident's medications could alter a person's mental status. EI #8 said Valium was an antianxiety medication which could cause confusion, somnolence (sleepiness) and fatigue. Naltrexone, an Opioid antagonist could cause dizziness. Risperadal, an antipsychotic medication could cause somnolence. Zanaflex, a muscle relaxant could cause somnolence. Baclofen, a muscle relaxant could cause drowsiness. Tegretol, a seizure medication could cause dizziness and drowsiness. Clonidine, a blood pressure medication could cause drowsiness and decrease a person's blood pressure. When asked if these medications could endanger the life or welfare of someone who was administered the medication but not prescribed the medications, EI #8 said yes. EI #8 commented, with the blood pressure medication, especially a low blood pressure could be dangerous. The hospital's Discharge Plan for RI #43 dated 11/6/2019, documented . Post Hospitalization Care Instructions: Pt (patient) was found to have ingested multiple medications that were not the patient's own medications. Please insure that whoever is giving (him/her) (his/her) medications is only giving (him/her) (his/her) own medications . ************************* On 12/14/2019 at 6:35 PM, the facility submitted a Removal Plan for F 760 which documented: 10/29/19: LPN #1 gave RI #14 medication's to RI #43 and vice versa. LPN #1 was disciplined with suspension. 11/11/19: LPN #1 was reported to Board of Nursing. Sponsors were notified and the Medical Director. Medical Director came to assess resident status and did progress notes in which they had no adverse reaction. Medication error report complete. The licensed staff will begin to review all recent labs on the residents for any significant changes. Medication error report completed. 11/19/19: Nurses were in serviced on medication errors by RN supervisors. Staff not in-serviced will be in-serviced upon returning to work. 12/13/19: Director of Nursing and/or Designee began an audit on medication pass observation to ensure medications are passed per physician orders. Random observation will start until medication error does not occur. Alleging the immediacy is removed on 12/14/19 ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 760 was lowered to a D level on 12/14/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL00037375.

Based on interviews and review of the POSITION DESCRIPTION DIRECTOR OF NURSING, the Position Description ADMINISTRATOR, the Time Line for (Employee Identifier {EI} #1, FATHER PURCELL MEMORIAL MEDICATION GASTROSTOMY CHECK OFF and Father Purcell Memorial In-Service Education Program, the facility's Administrator, responsible for directing all aspects of the facility, and the Director of Nursing (DON), responsible for the overall function of the nursing department, failed to ensure a thorough investigation was conducted after becoming aware that Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) had administered the wrong medications to Resident Identifier (RI) #14 and RI #43 on 10/29/2019. The administrative staff further failed to implement measures to ensure no other resident received the wrong medication after becoming aware RI #43 had been administered medications ordered for another resident, RI #14. During the 7:00 AM to 3:00 PM shift on 10/29/2019, EI #1, the LPN prepared medications for RI #14, who resided in the room next to RI #43. As she entered the room to administer the medications, she noticed RI #14 was not in the room; the resident was in the shower room. The LPN placed the unlabeled cup of medications in the top drawer of the medication cart. The LPN then proceeded to prepare RI #43's medications for administration. As the LPN entered RI #43's room, she noticed the resident was not in the room; the resident was in the shower room. The LPN then walked to the medication cart and placed another unlabeled cup of medications in the top drawer of the medication cart. When both residents were available, the LPN got the medication cups from the top drawer and administered them to each of the residents. RI #43 then left the facility via ambulance transport for a planned procedure at the hospital. When RI #43 arrived in the Emergency Room, the resident was noted to have a slow heart rate, slow breathing, and a low blood pressure. The resident was difficult to arouse with no spontaneous movement even to pain or sternal rub. RI #43 was admitted to the Pediatric Intensive Care Unit (PICU) due to the concern for serious illness in the setting of his/her altered mental status, risk of respiratory failure and other comorbidities. A urine drug screen was done, and it revealed RI #43 had medications in his/her system that were not ordered for the resident. After RI #43 was readmitted to the facility, EI #1 informed the facility's administrative staff that she had administered medications that belonged to RI #14 to RI #43 on 10/29/2019. These deficient practices affected RI #14 and RI #43, two of six residents who received medications from EI #1 on 10/29/2019 and placed RI #43, one of six residents receiving medication from the medication cart assigned to EI #1 on 10/29/2019 in immediate jeopardy as this failure was likely to cause serious injury, harm, impairment or death. On 12/14/2019 at 10:33 AM, the Administrator and Director of Nursing were notified of the finding of immediate jeopardy in the area of Administration, F 835. Findings include: The POSITION DESCRIPTION DIRECTOR OF NURSING signed by EI #3, the Director of Nursing on 9/4/2018, documented SUMMARY: Under the general direction of the Administrator, the Director of Nursing is responsible for planning, organizing, staffing, directing. Managing and coordinating nursing staff, equipment and supplies in such a manner as to afford optimum nursing care for the children served by the Center. RESPONSIBILITIES AND DUTIES: 1. Develops, or causes to be developed, implements and oversees conformance with such written nursing services policies, standards, practices and procedures as are needed to ensure the optimum care of each child served . In an interview on 12/12/2019 at 10:18 AM, EI #3, the DON was asked when she became aware that RI #43 had received the wrong medication. EI #3 stated, she couldn't remember the exact date, but she was at home when the Administrator, EI #2, called and informed her that EI #1, the LPN said she thought she (EI #1) was the one who administered the wrong medication to RI #43. After speaking with the Administrator, EI #3 stated she called EI #1, the LPN and informed her not to come into work until she was called. When asked if an investigation was conducted, EI #3 replied that she and the Administrator talked with EI #1; had EI #1 to write a statement; completed a medication error report; and reported EI #1's actions to the Board of Nursing. EI #3 commented, that's all we did. When asked whose medication did the facility determine was administered to RI #43, EI #3 answered that EI #1 told her they were RI #14's medications. EI #3 was asked if EI #1 reported to her how the error occurred. EI #3 replied by reading the statement written by EI #1. When asked if EI #1 informed her of what specifically occurred, EI #3 stated EI #1 didn't say what specifically occurred other than the fact that she mixed RI #43's medications up with another resident's medications. EI #3 was asked, what was done with the nursing staff after the incident was discovered. EI #3 answered that an in-service was conducted with the nurses about preparing medications one at a time and not storing prepared medications in the cart. EI #3 stated she completed a medication pass check-off with EI #1 during the 11:00 PM to 7:00 AM shift. EI #3 stated she will also begin to complete random observations of medication administration. When asked if there had been any random observations of EI #1, EI #3 answered that she would have to look in the book. In a follow-up interview on 12/13/2019 beginning at 12:32 PM, EI #3, the DON was asked did she review lab results of other residents after being informed by EI #1 that she had administered RI #43 medications that belonged to RI #14. EI #3 replied, no. EI #3 stated the facility only monitored the two residents whose medications were mixed up. When asked if the facility checked other residents to see if they may have received medications not prescribed to them, EI #3 said not to her knowledge. When asked what preventative measures were put in place to ensure the identified deficient practice did not recur, EI #3 stated the nursing staff was in-serviced to only pull (prepare) one medication at a time and if they were unable to administer the medication, to discard it and prepare again when the resident was available. EI #3 further stated that medication pass check-off was completed with EI #1 before EI #1 returned to the floor. An undated document titled Time Line for (EI #1) documented Sunday, November 10, 2019 3:14 p.m.: (EI #1) called the administrator and stated I have always been honest with you about everything except this one thing. I think I was the one that may have mixed (RI #43) medicine with (RI #14) medicine. I have been under a lot of stress lately but I know I did it. When the administrator asked why she waited so long to tell us what happened, (EI #1) then stated I don't know . The DON was notified immediately after I spoke with (EI #1) Sunday, November 10, 2019 3:18 p.m.: DON called (EI #1) and stated Don't come to work at your regular time and that they would call her when to come back to work. Monday, November 11, 2019 9:15 a.m.: . (EI #1) came into the facility she was asked to write out a statement about what happened. DON and Administrator made a report to the Board of Nursing of a medication error and medication error forms were completed. (EI #1) was suspended for 4 days . Friday, November 15, 2019 11:00 p.m. (EI #1) returned back to work on the 11 to 7 shift and the DON came in and did a Medication Pass check off with (EI #1) The FATHER PURCELL MEMORIAL MEDICATION GASTROSTOMY CHECK OFF indicated on 11/16/2019, EI #3, the DON observed EI #1 perform medication administration by way of a gastrostomy tube on one of the five residents who reside in Room Locator (RL) #4. The Father Purcell Memorial In-Service Education Program indicated on 11/19/2019 during the 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM shift, 20 of the facility's 58 licensed nurses received education by EI #4, the Registered Nurse Supervisor on Each nurse is to review FPM (Father Purcell Memorial) Medication Administration policy and abide by it. When administering medication each nurse is to only pull and administer one patient at a time medication. If you pull and store patients medication on cart, disciplinary action will be taken . On 12/13/2019 at 3:42 PM, EI #3, the DON was asked why in-service education was not started immediately after being made aware that a medication error had occurred. EI #3 replied, she did not know. During an interview on 12/11/2019 at 3:37 PM, EI #4, a Registered Nurse (RN) Supervisor acknowledged that she became aware of RI #43's urine drug screen results when the hospital staff called the nursing facility on 11/5/2019 and informed her that RI #43 had medications in his/her system that he/she was ordered to receive. EI #4 stated on 11/6/2019, EI #5, another RN Supervisor, showed her the RI #43's urine drug screen results. When asked if she apart of the facility's investigation into how RI #43 tested positive for medications he/she was not ordered to receive, EI #4 said no. In an interview on 12/12/2019 at 5:50 PM, EI #5, a RN Supervisor was asked when she became aware that RI #43 had been administered the wrong medication. EI #5 stated on the evening on 11/6/2019 after RI #43 had returned to the facility, she removed from the fax machine RI #43's urine drug screen results that were sent to facility from the hospital. When asked what type of investigation was done to see how RI #43 tested positive for medications he/she was not prescribed, EI #5 stated the only thing she knew was that she reviewed the labs and saw on the report the medications that RI #43 tested positive for and knew those medications belonged to RI #14. EI #5 stated she was not a part of any investigation. According to the fax confirmation report, on 11/5/2019 at 4:11 PM, the nursing facility received from the hospital the results of RI #43's Comprehensive Drug Analysis. The fax confirmation report dated 11/6/2019 indicated on 11/6/2019, the hospital staff faxed to the facility four pages regarding RI #43. The notes section of the report documented In regarded to (RI #43) medical records. These are all the labs that we have at this time. Looks like there are some labs that are still pending. I will send you another fax when all labs have been uploaded into our system . The fax confirmation report dated 11/7/2019 indicated on 11/7/2019, the hospital staff faxed to the facility 29 pages regarding RI #43. The notes section of the report documented In regards to (RI #43) medical records. All lab results are now available and have been included . The undated Position Description ADMINISTRATOR documented SUMMARY The Administrator is responsible . for effectively and efficiently planning, organizing, directing and controlling all aspects of the operation of Father Purcell Children's Center in a manner assuring quality care for the children, concern for their parents and satisfaction of all federal, state, and local laws and regulation governing nursing homes . During an interview on 12/12/2019 at 3:11 PM, EI #2, the Administrator stated on 11/10/2019, EI #1, the LPN called and informed her (EI #2) that she thought she had administered the wrong medications to RI #43. EI #2 stated she asked EI #1 when did this occur and EI #1 stated it happened on 10/29/2019, the day RI #43 was sent to the hospital. When asked who received RI #43's ordered medications, EI #2 stated the LPN (EI #1) told her that RI #14 received RI #43's medications. When asked what she did after becoming aware RI #43 had received the wrong medication, EI #2 stated the licensed nursing staff was asked to assess RI #43, the facility's Medical Director was notified and EI #1 was asked to not come into work until called. When asked if she instructed the facility to check other residents to see if they may have received medications not prescribed to them, EI #2 she didn't. EI #2 was asked if she was able to determine what happened, how it happened and who all was affected after being notified by EI #1, the LPN, that she had administered the wrong medication to RI #43 on 10/29/2019. EI #2 stated the facility concluded that EI #1 administered RI #43 medications that were ordered for RI #14. EI #2 stated she asked EI #1 several times how this occurred and EI #1 never verbally responded. According to EI #2, EI #1 gave her names of residents she thought had a medication error. When asked what preventative measures were put in place to ensure this did not recur, EI #2 stated the nurses will be checked-off on medication pass and the Consultant Pharmacy had been asked to perform check-off as well. EI #2 stated the Registered Nurses (RN) will begin monitoring medication pass and EI #1's employment will be terminated. During an interview on 12/12/2019 at 12:13 PM, EI #8, the facility's Consultant Pharmacist was asked when she became aware that RI #43 had received the wrong medications. EI #8 replied, today (12/12/2019). When asked what she had done after becoming aware RI #43 had been administered the wrong medication, EI #8 stated the Administrator asked her to perform a medication pass observation with EI #1. EI #8 stated she was planning on doing that when the LPN came into work. ************************* On 12/14/19 at 6:35 PM, the facility submitted a Removal Plan for F 835 which documented: The alleged incident that occurred on 10/29/19 FPM submitted the report online to ADPH on 12/14/2019. 12/14/2019: Department heads counseled on the importance of Abuse, Neglect and Exploitation and reporting neglect immediately and implementing the policies and procedures of the facility. Director of Nursing counseled on the importance of following up with staff after any significant change in resident but not limited to Abuse, Neglect, and exploitation. The facility will in-service the staff on the importance of reporting to ADPH per the Abuse, Neglect & Exploitation policy to include results of all investigations state survey agency with 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 835 was lowered to a D level on 12/14/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report number AL00037375.