**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documents, staff interviews, personnel record review, the State Agency complaint database, review of Police and Medical Examiner documents, and policies and procedures, the facility failed to ensure that one resident (#318) was free from neglect, by failing to ensure the resident was not administered oral medications through an intravenous line. Resident #318 coded and expired. The deficient practice could result in residents not being provided the necessary services to prevent harm. Findings include: Resident #318 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, bacteremia, moderate protein calorie malnutrition, acquired absence of specified parts of the digestive system, dementia and encephalopathy. Review of the admission Evaluation dated September 13, 2021 revealed the resident arrived to the facility on September 13, 2021 at 5:00 PM. The evaluation included the resident had severe decrease in food intake over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties. The evaluation also included resident #318 was receiving TPN (Total Parenteral Nutrition) and did not receive food by mouth. The evaluation further revealed the resident did not have enteral tube feeding devices, i.e. nasogastric tube, gastrostomy/PEG (percutaneous endoscopic gastrostomy) tube. The care plan initiated on September 13, 2021 revealed the resident had Diabetes Mellitus and was at risk for altered nutrition. Interventions included to administer medications as ordered. Review of the physician's orders dated September 13, 2021 included the following: -Atorvastatin Calcium 80 milligrams (mg) by mouth at bedtime for CAD (coronary artery disease) -Carvedilol 12.5 mg by mouth two times a day for hypertension, hold for systolic blood pressure (SBP) < 100 and/or heart rate (HR) < 60 with meals -Donepezil 10 mg by mouth at bedtime for dementia -Metformin 500 mg by mouth two times a day for DM-2 -Metoprolol Tartrate 25 mg by mouth two times a day for hypertension, hold for SBP < 100 and/or HR < 60 -May crush or liquefy medications, if not contraindicated. The physician orders dated September 13, 2021 also included for TPN at 80 milliliters per hour (ml/hr) intravenously (IV) every 24 hours for nutritional feeding and dextrose solution 10% at 80 ml/hr IV every shift for use if TPN is interrupted. Review of the MAR (Medication Administration Record) for September 2021, revealed Atorvastatin Calcium, Carvedilol, Donepezil, Metformin, and Metoprolol were given to the resident on September 14, 2021 at 8:00 PM. A Skin/Wound note dated September 14, 2021 revealed resident #318 had a single lumen PICC (Peripherally Inserted Central Catheter) in place (a type of intravenous tube inserted into a smaller vein in the arm that ends in a large vein near the heart). A nurse's note dated September 15, 2021 at 12:36 PM revealed an RN (Registered Nurse/staff #176) was at the nurse's station when she heard a call of code blue at approximately 8:12 PM to 8:15 PM, and that upon arriving at the room where the code was called she assessed the resident (#318). The note included that staff began CPR (Cardiopulmonary Resuscitation), 911 was called at approximately 8:20 PM - 8:25 PM, and the resident's spouse was notified and gave permission for hospital transport. The note included the paramedics told staff #176 at 9:00 PM, that the resident had expired. The note included the RN proceeded to delegate to staff to clean the resident, turn down the air conditioner in the room and complete proper evaluation when death occurs. Staff #176 then notified the resident's spouse that resident #318 had expired, and notified the DON (Director of Nursing) that the resident expired. Review of the facility's investigative report dated September 15, 2021 included a narrative report which detailed the following events that had occurred on September 14, 2021: -At 9:10 PM, a Charge Nurse (staff #176) notified the DON (staff #7) that a resident had expired, a code blue had been called, and that the resident's death was unexpected. The DON instructed the charge nurse to notify the medical examiner, which was then delegated to the RN (staff #182). -At 9:57 PM, staff #182 notified the DON that during medication administration resident #318 became diaphoretic and unresponsive. When the DON asked if the resident had aspirated, staff #182 stated that the resident had refused to take medications orally, and that the nurse had crushed the medications, dissolved them in water, and pushed the medications through the PICC line because he felt the resident should get the medications. The DON asked staff #182 additional questions to clarify that the nurse had dissolved the medications and injected the medications into the PICC line, which staff #182 confirmed. -At 10:10 PM, the DON notified the Administrator (staff #180) of the incident. -At 10:13 PM, the DON let staff #182 know via telephone that he would be removed from the assignment effective immediately and that he was suspended. -At 10:31 PM, Staff #182 confirmed verbally and in writing to the charge nurse what he had told the DON. -At 10:35 PM, Administrator and DON arrive at the facility. -At 10:45 PM, Staff #182 was interviewed by the Administrator, DON, and Senior [NAME] President of Clinical/Compliance Nurse and they let staff #182 know that he was suspended. Staff #182 was sent for a drug test. -At 11:30 PM, call from Medical Examiner's office, they declined the case. -At 23:40 AM on September 15, 2021, call made to spouse regarding mortuary arrangements. Spouse asked if they knew the cause of the resident's death. (A response to the spouse question was not included.) The narrative report also included that during the 3rd interview with staff #182, the RN stated that when he dissolved the medication tablets in lukewarm water to administer them through the PICC line, some of the tablets did not fully dissolve 100% and that some particles did not fully dissolve. The staff statement included staff #182 stated he used a prefilled 10 cc (cubic centimeter) syringe to administer approximately 2-3 syringes of the solution. Staff #182 stated that resident #318 started to appear sweaty, diaphoretic and unresponsive and that he flushed the PICC line, reconnected the PICC line to the TPN, and then called Code Blue. The narrative report included that the Charge Nurse responded to the Code Blue, CPR was initiated and that on September 14, 2021 at 8:59 PM paramedics pronounced resident #318 deceased . Interventions implemented after the incident included that on September 14, 2021 the resident's room was secured and the nurse cart was checked. The narrative report concluded that the facility was unable to substantiate the account of events provided by staff #182 because they were unable to locate proof of the syringes, medication cup/applesauce and because of other details provided by staff #182 in his statements. The report included that they retrieved the trash at approximately 11:30 PM on September 14, 2021 and check the trash for the entire building and that they were unable to locate the syringe in the location that staff #182 stated it would be. The report also revealed the RN's statement remained consistent regarding pushing the resident's oral medications through the resident's PICC line and the resident coded. Continued review of the facility investigative report dated September 15, 2021 included the following statements: -A handwritten statement dated September 14, 2021 at 10:30 pm from staff #182 that included that when staff #182 received resident #318, the resident was in bed, with TPN in progress and he offered the resident medications. The statement included that the resident stated the resident was unable to swallow, so staff #182 crushed the medications and mixed them with applesauce. Resident #318 refused to take the crushed medications mixed with applesauce, and staff #182 then crushed the same medications and administered the medications through the PICC line. Resident #318 became unresponsive, Code Blue was called, resuscitation and CPR was started, and the resident was pronounced dead at 8:59 PM. -A statement dated September 14, 2021 from an LPN (Licensed Practical Nurse/staff #65) included that she was a participant in the Code Blue and that she observed that resident #318 was not breathing and he was throwing up. The statement included that no pulse was found. -A statement dated September 15, 2021 by a Charge Nurse (staff #176) included that when she assisted with the Code Blue at approximately 8:12 PM on September 14, 2021, the code status of the resident was verified and CPR was initiated and paramedics were called. The paramedics pronounced the resident as deceased at 8:59 PM. She then called the resident's spouse and informed the spouse that resident #318 had passed away and remained on the phone to console the spouse. Review of the State Agency complaint database revealed that on September 15, 2021 at 1:24 PM, a report was received from the facility that resident #318 had died unexpectedly and that an investigation was ongoing. The facility report did not include any additional details and did not include that the resident's nurse had stated that he injected crushed pills into the resident's PICC line at the time of death, information that was known by management staff at the time of the report. A Police report dated September 15, 2021 included that the ME (Medical Examiners) office had contacted the Police and had stated the following: -On September 14, 2021 at approximately 9:00 PM the ME's office received a phone call from the facility to report an unexpected death and that based on the story told to the ME office, the ME had declined the case due to it being considered a natural death. -On the morning of September 15, 2021, a call was received from the DON (staff #7), who stated that she had reviewed the records for resident #318, and discovered that the resident's nurse had improperly administered the resident's medications, that the resident's nurse was supposed to give the medications orally, but instead had administered the medications intravenously and that is when the resident went into cardiac arrest and was unable to be saved. The DON included that resident #318 was pronounced dead at 8:59 PM. -The medical examiner included that the DON refused to provide the name of the nurse who had been responsible for resident #318, and when asked if the nurse had given the oral medications intravenously on purpose she stated that she did not know. The ME office included the DON was not forthcoming with information and would only answer questions asked of her, that it sounded like she was scared to even be making the call. The Police Department report also included that evidence seized by the police in their investigation was listed as a plastic bag containing a syringe, a medication cup and a cylinder which contradicted the facility report that they were unable to locate proof of the syringes, medication cup/applesauce. Review of a ME document revealed the facility was required to submit records to the ME office for death investigation. Review of the personnel record for staff #182 revealed a record of his orientation which included staff #182 was checked off for medication administration on July 7, 2021 by a preceptor. The personnel record also included a job description for the registered nurse that an RN is to prepare and administer medications as ordered by the physician and to be knowledgeable of nursing and medical practices and procedures. During a telephone interview conducted on October 5, 2021 at 1:33 PM with staff #182, he stated that on September 14, 2021 he attempted to give resident #318 medications at about 8:00 PM. The RN stated that the resident would not take the medications whole due to being unable to swallow the medications. Staff #182 stated that he crushed the medications and put them into applesauce. Staff #182 stated that the resident refused the medications crushed in applesauce due to being unable to swallow them. Staff #182 took the crushed medication and applesauce and discarded them into the trash on the medication cart, and obtained a new set of the same medications, crushed them and put them into lukewarm tap water to dissolve them. Staff #182 stated that he then aspirated the medications and water into a syringe and proceeded to push them into the PICC line. The resident became diaphoretic almost immediately and staff #182 stated he knew things were not going well and the resident began to fade away. When asked why he put the medications into a PICC line he stated that it occurred to him that if you can push medications thru a G (gastrostomy) tube, why not a PICC line? The resident gets TPN thru the PICC line just like a G tube. Staff #182 stated that he had never done that before, and that was not an acceptable practice, and not the policy of the facility either. Staff #182 stated that in that moment, it seemed like a good idea. During an interview conducted on October 6, 2021 at 6:06 AM with the ADON (Assistant Director of Nursing/staff #62), she stated that she assumed it was oral medications that staff #182 had pushed through a PICC line, because the resident had no physician's orders for medications to be given through the PICC line. Staff #62 stated that you cannot push medications through a PICC line like a G-tube, they cannot be treated the same, and they are not interchangeable. Staff #62 stated that a PICC line goes into the blood system and a G-tube is for medications and nutrition. Staff #62 stated that her expectation is that if a resident refuses medication, the nurse does not give the medication and contacts the physician. During an interview conducted on October 6, 2021 at 08:43 AM with an RPH (Registered Pharmacist/staff #212), he stated that oral medications cannot be given through a PICC line for many reasons. The RPH stated that they are not sterile, have coatings and /or binders that would not dissolve in a fluid and could damage a blood vessel and be potentially fatal. The RPH stated that the lack of being sterile could cause an infection in the patient and the coatings or binders would not dissolve in fluid which could cause pulmonary emboli, critical illness or could be lethal. The RPH stated that a pulmonary embolism would be apparent very quickly and would be potentially fatal. An interview was conducted on October 7, 2021 at 9:38 AM with the DON, who stated that when resident #318 expired, the resident's family was notified that the Medical Examiner's office was looking into the care of this resident, and that the facility did not discuss the cause of death because they are not doctors, and do not wish to speculate as to the cause of death of a resident. The DON stated that she was told by staff #182 that the resident coded while he was giving the resident the nighttime medications. She stated that staff #182 stated he had crushed the medications and put them through the PICC line, because the resident needed the medications. The DON stated that she asked him at that time if the medications were IV (intravenous) medications and staff #182 replied no, the oral medications were put through a PICC line. The DON stated staff #182 was terminated because he violated the facility policy for medication administration/5 rights of medication administration. The DON stated oral medications cannot be given through a PICC line because the particles in the blood system can cause emboli. The DON stated the incident was reported to the State as an unexpected death and the Administrator (staff #180) chose the reporting category. When asked if staff #182's actions were negligent, the DON replied that staff #182 violated the 5 rights of medication administration and that was possibly negligence in this case. She stated not giving a medication by the right route is a violation of the 5 rights of medication, and that she did not discuss potential negligence with the Administrator. The DON stated that the neglect is when someone does not provide services identified as necessary, and that it could also be negligence if someone is not providing the services accurately. However, the DON stated that she did not consider this incident negligence because it was a medication error. During a telephone interview conducted on October 8, 2021 at 8:21 AM with the facility Medical Director (staff #232), he stated that giving oral medications through a PICC line is an absolutely unacceptable practice, and that he has never experienced this type of incident in his career. The Medical Director stated that depending on how much medication was actually administered and what the medication was, the outcome would be catastrophic for the patient. In an interview conducted on October 8, 2021 at 8:45 AM with the administrator (staff #180), she stated that she initially had received a call from the DON, who reported that a nurse (staff #182) had reported administering an oral medication into a PICC line. The administrator stated while interviewing staff #182 he stated that he put medications into the resident's PICC line because he wanted to make sure that the resident received the medications. The administrator stated that she interviewed additional staff at that time and that she secured items from the resident's room and kept them for the detective. The administrator stated that the DON notified the family that the resident had an unexpected death, but did not discuss the possible causes, and that no one has told the family about the nurse putting the medications into the PICC line. The administrator stated I'm not a doctor so I do not have any opinion on the cause of death. During a follow-up interview conducted on October 8, 2021 at 9:58 a.m. with the DON, she stated that she had not told the family of the medication error because she was not sure exactly what happened as the story from staff #182 did not make sense. Review of the facility policy titled Abuse and Neglect-Clinical Protocol revealed neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy included that along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect; for example, inadequate prevention or care of pressure ulcers, inattention to advance directives and resident wishes, inappropriate management of problematic behavior, recurrent failure to provide incontinence care, failure to report or evaluate significant weight loss, repeated failure to check for correct application of restraints, etc. The policy also included the physician and staff will help identify risk factors for abuse within the facility; for example, issues related to staff knowledge and skill, or performance that might affect resident care. Review of a facility policy Abuse Prevention Program included that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.