**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure safe and effective medication use to meet the needs of residents when: a. Facility utilized the open medication administration scheduling, since January 2018, where the facility allowed a 4-hour window (such as 7 a.m. - 11 a.m. for daily; and 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. for twice daily administration times) for routine medication administration without addressing any exceptions (medications that did not fit this medication scheduling) such as types of medications and time-critical medications (those for which early or late administration greater might cause harm or have significant, negative impact on the intended therapeutic effect) such as insulin (medications to manage blood sugar), pain medications, anticonvulsant (seizure) medication, anti-Parkinson's medications, antibiotics, anticoagulants (blood thinners), etc.; b. The assignment of the open medication administration on the monthly medication administration records (MARs) was assigned by non-clinical staff members who had no training or licenses in clinical practice; c. The nursing staff member, who reviewed the monthly MARs for completeness and accuracy, did not review the MARs in relation to the 4-hour window scheduling for medications; d. The Consultant Pharmacist (CP) was not involved in the open medication administration decision, and did not identify the inappropriate medication administration scheduling for 8 of 15 sampled residents (Residents 3, 7, 8, 9, 15, 17, 20, and 25) in the monthly medication regimen review (MRRs); e. The facility did not conduct a quality assurance (QA) process (procedure ensuring quality of service) to assess and monitor whether this open medication administration process was safe and effective for residents since its implementation in January 2018. The failure resulted in: inappropriate scheduling of Resident 7's anti-seizure medication (phenytoin) that may have contributed to her experiencing a seizure on 1/11/20; two medication errors identified during the medication pass observation for Residents 17 and 25; medications with specific requirements (such as given with food, before food, on empty stomach, at the same time each day to maintain steady bloodstream level, etc.) were not given in accordance with the physician's orders, manufacturer's specifications, and/or accepted standards of practice for 10 of 15 residents (Residents 3, 7, 8, 9, 15, 17, 20, 25, 27, and 80); and the potential for significant, negative outcomes (such as too low/high blood sugar, inappropriate pain management, fluctuation of medication in the bloodstream for certain medications, seizure, stomach upset, etc.) for residents. On 1/14/2020 at 3:49 p.m., the survey team called Immediate Jeopardy (IJ) concerning Pharmacy Services, in the presence of the Executive Director (ED) and the Director of Nursing Services (DNS). The noncompliance in Pharmacy Services placed residents at risk for adverse outcomes (as stated above) related to inappropriate medication use, and also posed the potential for medication overdose (when given too close together) and/or inappropriate treatment (such as in appropriate pain management, too low/high blood sugar, fluctuation in blood level of medications) when given too far apart due to the wide window of medication administration. The facility provided the acceptable removal plan, and the IJ was removed on 1/15/2020 at 4:43 p.m. The removal plan, dated 1/15/2020, included discontinuance of the open medication administration process immediately; nursing staff and the CP reviewing medication orders for appropriate scheduling in accordance with the physician's orders and/or manufacturer's specifications; in-services provided to all nurses regarding the appropriate medication administration process and discontinuance of the open medication administration; identification of residents at risk with appropriate monitoring in place; and revision of the facility policy and procedures for medication pass times. Findings: A review of the facility's policy, Open Medication Administration, signed by the Medical Director (MD) on 1/25/18, indicated the following under Procedure: 1. The Center identifies the desire for open medication administration times, to meet the individual needs and preferences of the Resident population. 2. The Center works with the Medical Director to define open medication times. 3. The Center meets with Resident and Families through Resident/Family Counsel to present the open medication administration program prior to implementation. 4. Residents who do not wish to participate in open medication administration times are provided with the option to continue with standard administration times. The policy indicated, for once daily dosing, the open medication time was 7 a.m. - 11 a.m. (4-hour interval); and for twice daily dosing, the open medication administration times were: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. (4-hour interval). This policy did not specify exceptions, such as types of medications and/or time-critical medications, that did not fit the open medication administration; nor did it address who could designate the open medication administration scheduling. A review of the 2011 ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications, the Institute for Safe Medication Practices (ISMP), a nationally recognized organization focusing of safe medication practices, indicated that time-critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal [below standard] therapy or pharmacological [drug-related] effect. In this publication, ISMP specified time-critical medications as: opioids used for chronic pain (fluctuations in the dosing interval may result in unnecessary break-through pain), medications that must be administered apart from other medications (such as phenytoin, antacids), certain medications that require administration within a specified time before, after, or with meals; insulin; anti-infective; certain antidiabetic agents; etc. The ISMP publication also indicated, Policies should allow prescribers, pharmacists, or nurses to declare any scheduled medication to be time-critical . by including this designation with medication order and/or medication administration record (MAR) entry. 1. A review of the U.S. Food & Drug Administration's (FDA) FY2015 Regulatory Science Research Report: Narrow Therapeutic Index Drugs, it defined narrow therapeutic index (NTI) drugs as drugs where small differences in dose or blood concentration may lead to serious therapeutic failures and/or adverse drug reactions that are life-threatening or result in persistent or significant disability or incapacity. Phenytoin (brand name: Dilantin) is one of the NTI drugs. A review of the U.S. National Library of Medicine indicated phenytoin is used to control certain type of seizures, and to treat and prevent seizures. It indicated to take phenytoin at around the same time(s) every day and [i]f you are receiving . supplements through a tube feeding . You will need to allow some time between receiving your feedings and taking phenytoin. (https://medlineplus.gov/druginfo/meds/a682022.html, accessed 1/22/2020) During a medication pass observation on 1/13/2020 at 1:08 p.m., licensed vocation nurse (LVN) B was observed preparing a 6-milliliters (ml) of phenytoin liquid 125 milligrams per ml (total 150 mg) for Resident 7. At the bedside, LVN B was observed giving phenytoin via Resident 7's G-tube (gastrostomy tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications). After finishing giving the phenytoin, LVN B poured 225 mls of Isosource HN (an enteral feeding) into Resident 7's G-tube, followed by flushing of water. Shortly after the medication observation, LVN B stated, I always give it [the enteral feeding] before or after the Dilantin. A concurrent review of the facility's Nursing 2019 Drug Handbook with LVN B at this time indicated, Enteral tube feedings: May interfere with absorption of oral drug. Stop enteral feeds for 2 hours before and 2 hours after drug use. Monitor serum drug level more frequently. LVN B said she did not know the enteral feeding would interfere with the phenytoin absorption. A review of Lexi-comp online (www.[NAME].com), a nationally recognized drug information resource, indicated the following: Tube feedings: Tube feedings decrease phenytoin absorption . The manufacturer recommends not to administer concomitantly [at the same time] with an enteral feeding preparation. There is a variety of opinions on how to administer phenytoin with enteral feedings. Be consistent throughout therapy. Under Food Interactions, Lexi-comp indicated, If phenytoin is administered with enteral feeding preparations and/or related nutritional supplements, serum concentrations of phenytoin may be decreased. Management: Do not administer phenytoin concomitantly with an enteral feeding preparation. On 1/13/2020, a review of Resident 7's medical record indicated she was a [AGE] year old resident admitted to the facility with diagnoses including gastrostomy status, pain, and unspecified convulsions. Resident 7 was dependent on staff for all activities of living (such as bathing, toileting, getting dressed) and could not communicate her needs. Review of the medication orders indicated a physician's order, dated 1/12/2020, for phenytoin 150 mg via G-tube three times daily. Prior to 1/12/2020, she had a physician's order for phenytoin 150 mg via G-tube twice daily related to unspecified convulsions since 3/1/18. There was also a physician's order, dated 6/7/19, for Isosource HN, 225 ml to be given 4 times daily. The January 2020 MAR indicated it was scheduled to be given daily at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. A review of the November 2019 to January 2020 MARs indicated the facility scheduled twice daily phenytoin: 7 a.m. to 11 a.m. for the AM dose; and 3 p.m. to 7 p.m. for the PM dose until it was changed to three times daily on 1/12/2020. There was no time stamp of when the medication was given within this 4-hour window; there were only the nurses' initials indicating the medication was given. Thus, prior to 1/12/2020, Resident 7's phenytoin was not consistently given every day, and, due to the 4-hour window scheduling, it may be given with or without the enteral feedings since 3/1/18. During an interview on 1/13/2020, at 2:12 p.m. LVN B stated when the medication was scheduled from 7 a.m. to 11 a.m., the nurse had the flexibility to give it any time during the 4-hour window. She said, It depends on my schedule when I give it. On 1/13/2020, a review of Resident 7's medical record reflected she had an episode of seizure on 1/11/20, after which the phenytoin level was ordered and obtained. A review of the laboratory report, dated 1/12/2020, indicated the phenytoin level was 3.7 L[low] (normal range: 10 - 20 micrograms (mcg)/ liter(L)). The previous phenytoin level, obtained on 8/21/19, was 19.7 mcg/mL (normal range). Resident 7 did not have any new medication orders that may have interacted with the phenytoin, and her other laboratory tests (such as kidney and liver functions) remained consistent since 3/1/18. During an interview with LVN D on 1/14/2020 at 10:53 a.m. she stated the nurses had the flexibility to give scheduled medications within the 4-hour window if it was scheduled from 7 a.m. to 11 a.m. on the MAR. When questioned how she gave the phenytoin to Resident 7, she stated, I give it with the bolus feed [the enteral feeding]. When informed of the manufacturer's instructions not to give phenytoin with enteral feedings at the same time, she said, I didn't know. No one told me. The doctor didn't specify. During a telephone interview with the Medical Director (MD) on 1/14/2020 at 12:07 p.m. the MD stated she was aware of the open medication administration practice at the facility. The MD confirmed the facility did not specify exceptions to the open medication scheduling. She added, If you find those, give me a list and next time we order we will specify. The MD further explained that the nurses made the determination when to give the medications, as she only gave orders for how often, such as once or twice daily, to give the medications. The MD agreed phenytoin liquid is a short acting medication, and should be given consistently every day to maintain steady bloodstream level. The MD stated the most recent phenytoin level was low (3.7 mcg/mL) and could be caused by the way the medication was given. During an interview with the DNS on 01/14/2020 at 12:21 p.m., she said the open medication administration was a corporate change policy, meaning it was a corporate-mandated change. She explained, when a resident was admitted to the facility, the nursing staff handwrote the medications and the specific times (such as 9 a.m. for daily dosing, and 9 a.m. and 5 p.m. for twice daily dosing) on the handwritten MAR. Then at the end of the month, the Medical Records staff (namely the Health Information Manager [HIM]) entered the orders into the computer and changed some of the once-daily and twice-daily scheduled medications to open medication administration scheduling. DNS was uncertain how the HIM made the determination which medications to convert to open medication scheduling. She continued, the recap nurse (LVN A) would review the monthly computer-generated MARs for completeness and accuracy. The DNS stated the HIM left her employment in December 2019, but ran the January 2020 MARs before she left. During an interview with the Business Office Manager (BOM) on 1/14/2020 at 12:59 p.m., the BOM stated she was also doing interim medical records. She stated she entered the MARs in the computer and they were then checked by LVN A. During an interview on 1/14/2020 at 1:50 p.m., LVN A said she reviewed the monthly MARs for completeness and accuracy. LVN A stated the nurses did not have access to the computer; it was the HIM who input the physician's orders into the computer and generated the MARs. She stated it was the HIM who converted the specific time administration (such as 9 a.m.) from the handwritten MAR to the open medication administration scheduling on the computer-generated MAR. She explained, when she reviewed the computer-generated MARs, she did not pay attention to the open medication scheduling, that she only paid attention to the medication orders and the frequency. She stated, when she first started employment at the facility, she questioned the open medication administration practice, but the HIM told her it was the facility's policy that allowed it. During a telephone interview with the CP on 1/14/2020 at 2:07 p.m., the CP stated he started consulting at the facility since 11/2018, at which time the facility already implemented the open medication administration. The CP stated phenytoin liquid is a short acting medication, and putting it on the open medication scheduling gave the leeway for nursing staff to not give it consistently every day. During a concurrent review and interview on 1/15/2020 at 2:03 p.m., the DNS reviewed the personnel files for both the HIM and BOM, and confirmed they had no training or licenses in clinical practice. During an interview on 1/15/2020 at 4:07 p.m., the CP stated he had a chance to review Resident 7's medical record. He said, I agree there was some inconsistency when the medication [phenytoin] was given and whether it was the cause of the seizure. There also could be an issue with giving with the tube feeding. The CP stated, I was unaware the enteral feeding was given with the Dilantin. 2a. During a medication administration observation on 1/13/2020 at 9:26 a.m., LVN A was observed giving six medications to Resident 25. Included in the medications was a tablet of metformin (a diabetes medication) 1,000 milligrams (mg, unit of weight). During the medication pass, Resident 25 stated he had breakfast between 7:30 a.m. to 8 a.m. that morning. During the medication pass, a review of the pharmacy label on Resident 25's metformin indicated, Give 1 tablet by mouth twice daily with morning and evening meals. On 1/13/2020, a review of Lexi-comp online indicated, Drug may cause GI [gastrointestinal - related to stomach/intestine] upset; take with food (to decrease GI upset). Take at the same time(s) each day. On 1/13/2020, a review of the physician's order Metformin 1000 mg by mouth two times a day related to diabetes, dated 9/19/19. On 1/13/2020, a review of Resident 25's January 2020 MAR indicated the facility assigned the medication administration times for metformin from 7 a.m.-11 a.m. and 3 p.m. to 7 p.m., when it should have been scheduled with meal times. During an interview on 1/13/2020 at 3:56 p.m., LVN A reviewed pharmacy label and acknowledged metformin was given at least 1.5 hrs after food, inconsistent with the manufacturer's specifications. 2b. During another medication pass observation on 1/13/2020 at 10:10 a.m., LVN A was observed giving 14 different medications to Resident 17. Included in the medications was a tablet of potassium (to treat low potassium level in the blood) 10 milliEquivalent (mEQ, unit of measure). LVN A said Resident 17 had breakfast around 730ish that morning. The medication administration time was at 10:10 a.m. (more than 2.5 hours later). A review of the physician's order, dated 4/1/18, indicated to give potassium chloride 10 MEQ by month one time a day related to hypokalemia (low potassium in the blood) WITH BREAKFAST. A review of the MAR, dated January 2020, indicated the facility assigned the medication administration time for potassium from 7 a.m. to 11 a.m. daily when the order indicated to give with breakfast. A review of Lexi-comp online indicated oral dosage forms of potassium should be taken with meals and a full glass of water or other liquid to minimize the risk of GI irritation. During an interview on 1/13/2020 at 4:03 p.m., LVN A said potassium should be scheduled around 8 a.m. and confirmed it should be given with breakfast as per the physician's order. 3. On 1/15/2020, a review of the sampled resident's medical records reflected the following medications not given in accordance with the physician's orders, manufacturer's specifications, and/or standards of practice: a. Resident 3 was admitted to the facility with diagnoses including type 2 diabetes. Her medication orders included a physician order, dated 1/1/19, for metformin 850 mg two times daily for type 2 diabetes. A review of her January 2020 MAR, indicated metformin was scheduled: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. A review of Lexi-comp online indicated, Drug may cause GI upset; take with food (to decrease GI upset). Take at the same time(s) each day. b. Further review of Resident 7's medical record also indicated a physician's order, dated 8/12/19, for hydrochlorothiazide (a medication to treat high blood pressure and fluid retention) via G-tube in the afternoon for high blood pressure. A review of her January 2020 MAR, indicated it was scheduled to be given daily from 3 p.m. to 7 p.m. A review of Lexi-comp online indicated to give hydrochlorothiazide: Administer early in day to avoid nocturia [nighttime urination]. Take the last dose of multiple doses no later than 6 PM unless instructed otherwise. c. A review of Resident 8's medical record reflected a physician's order, dated 11/8/19, for levetiracetam (an anticonvulsant) 500 mg once time a day related to unspecified convulsions. A review of her January 2020 MAR, indicated it was scheduled to be given daily from 7 a.m. to 11 a.m. A review of an article, Taking Your Medication Regularly is Essential to Controlling Your Seizures, by the Epilepsy Foundation, dated 8/2018, it indicated, Seizure medicines must be taken each and every day as prescribed. If the right amount is not taken at the right time, the medicine may not be able to prevent seizures, or might cause unwanted side effects. (https://www.epilepsy.com/learn/treating-seizures-and-epilepsy/seizure-and-epilepsy-medicines/importance-taking-medication; accessed 1/22/2020) d. A review of Resident 9's medical record indicated she was admitted to the facility with diagnoses including type 2 diabetes. Her medication orders included the following: - Basaglar Kwikpen (insulin glargine, to control blood sugar) 18 units subcutaneously (under the skin) one time a day for diabetes, dated, 2/27/19. A review of the January 2020 MAR, indicated it was scheduled to be given from 7 a.m. - 11 a.m. daily. Lexi-comp online indicated: Insulin glargine should be administered consistently at the same time each day. - Glipizide (to treat type 2 diabetes) 5 mg by mouth two times daily for type 2 diabetes, dated 10/12/19. A review of the January 2020 MAR, indicated it was scheduled to be given: 7 a.m. - 11 a.m. and 3 p.m.- 7 p.m. daily. Lexi-comp online indicated to give glipizide 30 minutes before a meal to achieve greatest reduction in postprandial hyperglycemia [high blood sugar after eating]. - Metformin 1,000 mg twice daily for type 2 diabetes, dated 4/1/18. Review of the January 2020 MAR showed it was scheduled scheduled to be given: 7 a.m. - 11 a.m. and 3 p.m.- 7 p.m. daily. Lexi-comp online indicated to take with food (to decrease GI upset). Take at the same time(s) each day. - Klor-Con 10 mEQ (potassium supplement) once daily for low potassium in the blood, dated 4/1/18. A review of the January 2020 MAR, indicated it was scheduled to be given from 7 a.m. - 11 a.m. Lexi-comp online indicated Klor-Con should be taken with meals and a full glass of water or other liquid to minimize the risk of GI irritation. e. Resident 15 was admitted to the facility with diagnoses including unspecified dementia (a condition characterized by memory loss). A review of her medication orders indicated a physician's order for Aricept (for dementia) 5 mg by mouth in the evening, dated 12/19/19. A review of the January 2020 MAR, it was scheduled to be given daily from 3 p.m. to 7 p.m. A review of Lexi-comp online indicated to administer Aricept at bedtime. The facility scheduled bedtime medications at 9 p.m. d. Further review of Resident 17's medical record indicated she was admitted to the facility with diagnoses including unspecified pain and unspecified constipation. A review of her medication orders indicated: - Linzess (to treat constipation) 290 mcg by mouth in the morning, dated 5/1/18. A review of the January 2020 MAR, indicated it was scheduled to be given from 6 a.m.- 10 a.m. Lexi-comp online indicated to give Linzess at least 30 minutes before the first meal of the day on an empty stomach. - Hydrochlorothiazide 12.5 mg one time daily for high blood pressure, dated 4/1/18. A review of the January 2020 MAR, indicated it was scheduled daily from 7 a.m. - 11 a.m. Lexi-comp online indicated to give it early in day to avoid nocturia. - Tramadol (an opioid pain medication) 100 mg by mouth two times daily for unspecified pain, dated 4/1/18. A review of the January 2020 MAR, indicated it was scheduled: 7 a.m. - 11 a.m. and 3 p.m.- 7 p.m. daily. A review of the ISMP publication (as indicated above) indicated opioids used for chronic pain should be given consistently at the same time every day as fluctuations in the dosing interval may result in unnecessary break-through pain. During an interview on with Resident 17 on 1/16/2020 at 9:18 a.m., Resident 17 stated she had a slipped disc (herniated cervical disc in the neck) and had pain behind her neck radiating to her back. She stated sometimes the pain was so bad she needed a Tylenol on top of the Tramadol. f. A review of Resident 20's medical record indicated she was admitted to the facility with diagnoses including anxiety and high blood pressure. A review of her medication orders reflected the following: - Losartan (for high blood pressure) 50 mg one daily for pulmonary hypertension (high blood pressure in the arteries of the lungs), dated 9/5/19. A review of the January 2020 MAR, indicated it was scheduled to be given: 7 a.m. - 11 a.m. daily. A review of Lexi-comp online indicated to administer without regard to meals; however, administer consistently with respect to food intake at about the same time every day. - Metolazone (for high blood pressure and water retention) 2.5 mg one time daily unspecified edema (swelling), dated 9/5/19. A review of the January 2020 MAR, indicated it was scheduled: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. A review of Lexi-comp online indicated to give metolazone: Therapy should be taken early in the day to avoid nocturia. - Omeprazole (to prevent heartburn) 20 mg in the morning for gastroesophageal reflux (reflux of acid), dated 9/5/19. A review of the January 2020 MAR, indicated it was scheduled to be given: 7 a.m. - 11 a.m. daily. A review of Lexi-comp online indicated to administer omeprazole 30 to 60 minutes before a meal; best if taken before breakfast. g. A review of Resident 25's medical record indicated he was admitted to the facility with diagnoses including type 2 diabetes. A review of his medication orders indicated: - Insulin Lispro (a short acting insulin, to manage high blood sugar) 5 units subcutaneously one time a day for type 2 diabetes, dated 11/5/19. A review of the December 2019 MAR, indicated it was scheduled daily from 11 a.m. to 2 p.m. (3-hour window). A review of Lexi-comp online indicated: Insulin lispro should be administered within 15 minutes before or immediately after a meal. - Levothyroxine 112 mcg by mouth in the morning for hypothyroidism (thyroid gland doesn't produce enough thyroid hormone), dated 10/1/19. A review of the January 2020 MAR,indicated it was scheduled to be given daily from 6 a.m. to 10 a.m. A review of Lexi-comp online indicated to administer consistently in the morning on an empty stomach, at least 30 to 60 minutes before food. Alternatively, may consistently administer at night 3 to 4 hours after the last meal. h. A review of Resident 27's medical record indicated he was admitted to the facility with diagnoses including type 2 diabetes. A review of his medication orders indicated a physician's order, dated 12/27/19, for metformin 1000 mg two times daily for type 2 diabetes. Review of the January 2020 MAR, indicated it was scheduled: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. daily. A review of Lexi-comp online indicated to administer metformin with food (to decrease GI upset). Take at the same time(s) each day. j. A review of Resident 80's medical record indicated he had a physician's order, dated 12/28/19, for Flomax (for enlarged prostate) once daily for urinary retention. A review of the January 2020 MAR, indicated it was scheduled daily from 3 p.m. - 7 p.m. A review of Lexi-comp online indicated Flomax should be given 30 minutes after the same mealtime each day. 4. During a telephone interview with the MD on 1/14/2020 at 12:07 p.m., the MD stated the QA Committee met every three months to go over data, but had not discussed open medication administration times as part of the QA evaluation and monitoring since implementation in January 2018. During a telephone interview with the CP on 1/14/2020 at 2:07 p.m., the CP stated there were no medications exempt from the open medication administration, and made recommendations related to open medication scheduling as he caught them during the monthly MRRs. The CP agreed having a 4-hour window gave leeway for the nursing staff to give the medications too far apart (such as 7 a.m. for the AM dose, and 7 p.m. for the PM dose; or 12 hours apart), or too close together (such as 11 a.m. for morning dose, and 3 p.m. for the p.m. dose; or 4 hours part), this could potentially lead to overdose of medications (such as opioids) when given too close together. Also, certain medications, such as anti-seizure medications, were not given on consistent basis to maintain the steady level in the bloodstream. In regard to QA process, the CP stated, I am not aware of any QA process. I have been in some QA meetings. I did recognize there was a part where the medication time frame was identified. During an interview with the CP on 1/15/2020 at 4:07 p.m., the CP was asked if he had identified in the MRRs regarding the incorrect scheduling for medications that had specific requirements for: Resident 3's metformin; Resident 7's phenytoin and hydrochlorothiazide; Resident 8's levetiracetam; Resident 9's insulin glargine, metformin, and Klor-Con; Resident 15's Aricept; Resident 17's Linzess and tramadol; Resident 20's omeprazole; and Resident 25's insulin lispro and levothyroxine. The CP stated he did not recall making these recommendations. He agreed, certain types of medications such as insulin, anti-seizure (phenytoin and levetiracetam), and pain medications (such as tramadol) should be given consistently at the same time every day. He stated he relied on the nurses to give the medications correctly. He acknowledged the nurses did not document the time the medications were given, so he could not confirm they were given appropriately. On 1/16/2020, a review of the MRR Binder (a book consisting of the CP's recommendations to the facility) for Year 2019 reflected there were no CP's recommendations related the incorrect scheduling for the residents mentioned above. This was confirmed with the DNS during a concurrent interview and review of the MRR binder on 1/16/2020 at 1:35 p.m. During a review of the facility's policy and procedure, MONITORING OF MEDICATION ADMINISTRATION, dated August 2018, indicated The consultant pharmacist evaluates medication administration to verify that the resident has received medications in accordance with the prescriber's orders and facility policy . A review of the facility's policy and procedure, CONSULTANT PHARMACIST REPORTS .MEDICATION REGIMEN REVIEW [MRR], dated August 2018, indicated The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record . medication administration administration records (MARs) . Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing, Medical Director and/prescriber as appropriate.