**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff followed the Policy and Procedure (P&P) titled Lifting machine, using a mechanical when transferring residents from the bed to a chair for two out of three residents (Residents 1 and 2). A mechanical lift is a metal assistive device with a U-shaped base, an overhead bar and a sling that work together to lift, reposition, and lower a resident into a chair or a bed. On 6/23/2023, Resident 1 was being transferred with a mechanical lift from her bed to a shower chair by one staff member (Certified Nursing Assistant (CNA) A). During the transfer, one of the straps from the sling became disconnected, which resulted in Resident 1 falling out of the sling onto the floor. Resident 1 sustained head injuries and lacerations to the left arm, requiring an emergency room transfer and admission to the hospital. Resident 2 also required a mechanical lift transfer. During an interview on 6/28/2023, Resident 2 stated that approximately 2-3 times a month, only one staff member uses a mechanical lift to transfer her from the bed to the chair. The failure to ensure two staff members were present during mechanical lift transfers resulted in Resident 1 to fall, sustained head injuries and lacerations to the left arm, requiring an emergency room transfer and admission to the hospital. This failed practice also had the potential for other residents that use the lift to fall. Findings: On 6/26/2023 at 8:42 a.m., the facility notified the California Department of Public Health that on 6/23/2023, at approximately 3:35 p.m., Resident 1 sustained lacerations to her left forearm, laceration to the bottom of her lip, bruising to her right arm/elbow and crepitus (grating sound) to an area above her eyebrow after falling from a mechanical lift to the ground. Clinical record review for Resident 1 was conducted on 6/28/2023. Review of Resident 1's Emergency Department Provider Report, dated 6/23/2023, indicated Resident 1 was brought to the emergency room after falling from a mechanical lift at the skilled nursing facility. The resident groaned in discomfort. Examination of her head indicated a laceration to her right forehead region requiring suture repairs, a right eye hematoma (bleeding around the eye), abrasion to the lips and dried blood in her mouth. Her left lower leg had a small hematoma on the front of her shin. A computerized tomography (CT scan - combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside the body. CT scan images provide more-detailed information than plain X-rays do.) indicated Resident 1 also sustained a right-sided subdural hemorrhage (bleeding in the brain). Review of Resident 1's hospital Neurosurgery (medical discipline that specializes in surgery performed on the nervous system, especially the brain and spinal cord) Consultation Note, dated 6/23/2023, indicated no surgery would be performed and that the subdural hematoma was potentially life-threatening. The family requested comfort care only (symptom control, pain relief, and quality of life). Review of the facility's P&P, Lifting machine, using a mechanical (revised 7/2017) indicated, . at least two nursing assistants are needed to safely move a resident with a mechanical lift. Steps in the procedure (using the lift) included, .to make sure the straps to the sling bar are securely attached to the clips and that it is properly balanced, before the resident is lifted, double check the security of the sling attachment and lift the resident two inches from the surface (bed) to check the stability of the attachments, the fit of the sling, and the weight distribution. Review of the manufacturer's manual titled Manual/electric Portable Patient Lift Owner's Installation and Operating Instructions, dated 2001, showed warning: when elevated a few inches off the surface of the bed and before moving the resident, check again to make sure that the sling is properly connected to the hooks of the swivel bar. Review of the facility's Unusual Occurrence Initial Report, dated 6/24/2023, indicated, on 6/23/2023 at approximately 3:35 p.m., Licensed Vocational Nurse (LVN) C was called to Resident 1's room after it was reported Resident 1 had fallen. The nurse found Resident 1 on the floor laying on her right side on top of one of the Hoyer legs with CNA A by her side. Resident 1 sustained lacerations to her left forearm, laceration to her bottom lip, bruising to her right arm/elbow and crepitus (grating sound) was noted to her forehead above her eyebrow. The maintenance staff checked the mechanical lift and sling and noted both were functioning properly. Review of Resident 1's Unusual Occurrence Final Report indicated that, on 6/23/2023 at approximately 3:35 p.m., LVN C was called into Resident 1's room by a CNA. LVN C stated she saw Resident 1 lying on the ground and there was blood on the floor. LVN C yelled for additional staff to help with Resident 1. CNA A stated she went to transfer Resident 1 with the mechanical lift and a sling. She placed the sling under the resident and hooked the straps to the machine. CNA A stated she lifted Resident 1 off the bed (with the lift) and pulled the machine towards the right to place Resident 1 into a shower chair, when the resident started to fall towards her right side. CNA A's statement included, I was by myself transferring the patient (resident). I am aware that this is not the proper protocol. The Director of Nurses (DON) documented, the facility concluded that the resident fell from the Hoyer lift (mechanical lift) due to CNA error. Review of Resident 1's admission Record face sheet (summary overview of the resident's important information) indicated she was admitted to the facility with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or inability to move on one side of the body) affecting her right-side (arm and leg), right-hand contracture (deformity) and unspecified dementia (decreased memory and thinking capabilities). Review of Resident 1's Minimum Data Set (MDS-an assessment tool) dated 4/12/2023, indicated she required extensive assistance from two staff members for transfers. Her balance during transfers indicated she was not steady and required stabilization with staff for assistance. Review of Resident 1's care plan to address her activities of daily living (ADL) care indicated on 8/12/2020, she was total dependent with transfers via a mechanical lift, which requires two people. Review of Resident 1's Progress Note, dated 6/23/2023 at 3:35 p.m., indicated Resident 1 sustained lacerations to her left forearm (approximately 8 centimeters (cm)) and to the bottom of her lip (approximately 3 cm), bruising to her right arm/elbow and crepitus to her forehead above her eyebrow. Review of Resident 1's Post-Fall Review form, dated 6/23/2023 at 3:50 p.m., indicated the Interdisciplinary Department Team (IDT) determined the root cause of the fall to be when the resident fell from the mechanical lift, the resident had no trunk control and no ability to brace herself due to hemiparesis and hemiplegia (paralysis) to her right side coupled with contractures (deformity). Review of CNA A's Performance Skill Check lists show she had met her return demonstration on the proper transferring and safety of a mechanical lift dated 12/14/2022 and again on 3/20/2023. Review of the Maintenance Safety Inspection Checklists for the two mechanical lifts, dated 6/7/2023, indicated the lifts were inspected and in proper working order. Another checklist dated 6/23/2023, was performed following Resident 1's incident. Both lifts were inspected and were in proper working order. An interview was conducted with the Director of Nursing (DON) on 6/28/2023 at 10:25 a.m. She stated Resident 1 was not able to make her needs known and her right arm and leg were contracted. The DON stated, on 6/23/2023 at approximately 3:30 p.m., she was notified of Resident 1 being on the floor. She stated when she entered Resident 1's room, only CNA A was in the room. The DON stated the mechanical lift was upright and the sling's straps were still attached except the front right strap (near the foot). She stated Resident 1 was on the floor, her torso was on top of the leg of the mechanical lift and the resident's left hand was grasping the lift. The DON stated Resident 1 was moderately bleeding above her right eyebrow, nose, and mouth. She stated further assessment of Resident 1 indicated the resident had a skin tear to her left forearm, bruises to her right elbow and her lip was bleeding. The DON stated she assessed the sling and there were no visible signs of rips or tears on the sling/straps. She confirmed two staff members should be transferring a resident when a mechanical lift was to be used. On 6/28/2023 at 12:05 p.m., an interview was conducted with the Maintenance Director. He stated he checked the mechanical lifts monthly and the lifts are in proper functioning order. The Maintenance Director stated he performed a routine maintenance check on the mechanical lifts on 6/7/2023, and the lift was functioning properly. He was asked to recheck the lifts on 6/23/2023, after Resident 1 had fallen during a transfer and the lift and slings were in good working order. During an interview on 6/28/2023 at 1:45 p.m., CNA E stated Resident 1 was nonverbal and unable to make her needs known. She stated Resident 1 was unable to stand and required the use of a mechanical lift during transfers. CNA E stated two staff are required to assist when using a mechanical lift. On 6/28/2023 at 4:40 p.m., a telephone interview was conducted with CNA A. She stated Resident 1 was nonverbal and could move one arm, but her legs were contracted. She stated she was aware two staff members are needed to use the mechanical lift and she had previously asked another CNA to help her transfer Resident 1 with the mechanical lift, but the CNA never came back into the room, so she transferred the resident by herself. CNA A stated when she started to move the mechanical lift, the left strap came off and Resident 1 fell out of the sling. On 6/28/2023 at 6:34 p.m., a telephone interview was conducted with LVN C. She stated Resident 1 was nonverbal, moans and cries. LVN C continued to state Resident 1's right arm was flaccid (limp), and her left leg was contracted. She stated, on 6/23/2023 at approximately 3:30 p.m., CNA B came to the nurses' station and notified her that a resident was on the floor. LVN C stated when she entered Resident 1's room, she saw Resident 1 on the floor on top of the mechanical lift and a lot of blood was on the floor. She stated Resident 1's head sustained a laceration to the right side of her head. LVN C stated the sling was still attached to the mechanical lift; however, one of the straps was not hooked. She stated two staff members are needed when a resident was to be transferred using a mechanical lift. A telephone interview was conducted on 6/28/2023 at 6:45 p.m. with CNA B. She stated Resident 1 was nonverbal and unable to move her extremities. CNA B stated two staff members are needed for a resident to be transferred using a mechanical lift. Clinical record review for Resident 2 was conducted on 6/28/2023. Resident 2 was admitted to the facility with diagnoses including lack of coordination. Her MDS dated [DATE] indicated a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact). Resident 2 required extensive assistance of two staff members for transferring. Review of Resident 2's care plan problem to address her performance deficit related to muscular impairment, dated 5/31/2017, indicated she required two staff members to transfer via a mechanical lift. On 6/28/2023 at 2:30 p.m., an interview was conducted with Resident 2. She confirmed she requires a mechanical lift to transfer from the bed to her wheelchair. Resident 2 stated sometimes there is only one staff member doing the transfer because they cannot find any other staff member to help them. She stated this usually happens two to three times a month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide routine medications to meet the needs of residents for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 did not receive his Keppra (generic name: levetiracetam, a medication to treat seizure disorder [a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness]) for 48 hours due to the medication not being available. The nursing staff did not notify the physician when the medication was not available to give, nor did they follow up with the pharmacy to receive the medication timely. The failure resulted in Resident 1 experiencing multiple episodes of seizures, became unresponsive while being transferred to Emergency Department (ED), and was hospitalized for treatment. 2. Resident 2 did not receive her Keppra due to medication not available x 1 dose. This failure placed Resident 2 at risk to experience seizures, falls, and injuries related to seizures. Findings: According to an online publication titled Missed Medicines as a Seizure Trigger by the Epilepsy Foundation, it indicated, Missing doses of seizure medicine is the most common cause of breakthrough seizures. Missed medicines can trigger seizures in people with both well-controlled and poorly controlled epilepsy. Seizures can happen more often than normal, be more intense or develop into long seizures called status epilepticus. Status epilepticus is a medical emergency and can lead to death if the seizures aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels. (https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines; accessed 3/22/23) 1. On 3/17/23, a review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including multiple sclerosis (a disabling disease of the brain and spinal cord where immune system attacks the protective sheath [myelin] that covers nerve fibers and causes communication problems between your brain and the rest of your body), muscle weakness, abnormality of gait and mobility, and epilepsy (also called seizure disorder). A review of Resident 1's Minimum Data Set (MDS, a care area assessment and screening tool), dated 2/1/23, indicated he had a BIMS score of 12 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated his cognitive condition was moderately impaired. Further review of Resident 1's clinical record indicated a physician's order, dated 7/28/22, for Keppra 500 milligrams (mg, unit of measurement), Give 1,000 mg by mouth two times daily for seizures. The facility scheduled it to be given daily at 9 a.m. and 5 p.m. Resident 1 was also receiving Dilantin (anti-seizure medication) 100 mg, 2 capsules in the morning and 2 capsules in the evening, starting 1/29/23. A review of Resident 1's March 2023 medication administration record (MAR) indicated Keppra tablets were not administered for 48 hours, on 3/3/23 at 9 a.m. and 5 p.m. and 3/4/23 at 9 a.m. and 5 p.m., as follows: a. On 3/3/23: 9 a.m. entry: Code 10 entered by registered nurse (RN) A; 5 p.m. entry: Code 10 entered by RN B b. On 3/4/23: 9 a.m. entry: Code 10 entered by licensed vocational nurse (LVN) C; 5 p.m. entry: Code 10 entered by RN B The MAR's Chart Code indicated each number code had a different meaning, such as 1 = resident refused, 2 = resident not available. The 10 code meant Other (specify). A review of the corresponding nursing progress notes indicated the following: a. 3/3/23 at 9:21 a.m., RN A wrote Keppra Tablet 500 mg .[dosing and frequency] . on order b. 3/3/23 at 4:17 p.m., RN B wrote: Keppra Tablet 500 mg . on order c. 3/4/23 at 10 a.m., LVN C wrote: Keppra Tablet 500 mg . on order d. 3/4/23 at 4:28 p.m., RN B wrote: Keppra Tablet 500 mg . on order Further review of Resident 1's clinical record indicated the nursing progress notes, documented by RN B on 3/5/23 at 2:20 a.m., indicating: 3/4/23 at 2330, Resident started having seizures 5x [meaning 5 times] lasting more than 3 minutes. Turned resident on his side to avoid aspiration [accidental breathing in of food or fluid into the lungs]. VS [vital signs] taken. Afebrile [not feverish]. MD [physician] notified with order to send to ER [Emergency Room] for further eval[uation] . A review of the 3/5/23 Emergency Medical Services (EMS) Prehospital Care Report w/o [without] Attachments, provided by the hospital, indicated: Responded to seizures. Upon arrival pt [patient] found lying left lateral position . postictal [period of time immediately following a seizure] . Per staff pt has been witnessed to have multiple seizures starting at approx. 23:45 tonight. Per staff pt has a history of seizures . Pt is noted to have shaking of extremities and pt reports impending seizure. Pt is noted to have a full-body generalized seizure lasting approx. 2 minutes. Pt administered 2.5 mg Versed [medication to treat seizures] IM [intramuscularly, meaning deep muscle injection] . Pt is noted to be unresponsive . During transport pt remained altered and unstable. At hospital pt moved to Emergency Department . A review of the acute care hospital's History and Physical (document that provides concise information about a patient's history and exam findings at the time of admission), date of service 3/5/23 at 4:55 a.m., indicated the hospital received Resident 1 for Chief Complaint of seizure. Under History of Present Illness (HPI), a hospital's physician wrote, [Age of resident] year-old male, institutionalized due to multiple sclerosis, presents with seizures. He has a longstanding seizure disorder for which he takes Dilantin and Keppra. The patient had 2 seizures in the nursing home for which 911 was called. He seized again for paramedics and they gave him intramuscular Versed at least twice. Seizure. When the patient got to the emergency room. However he was postictal and unresponsive. Dilantin level was subtherapeutic [lower than normal range] and it turns out the nursing home ran out of Keppra 48 hours ago. Under Plan, the H&P indicated, [Age] year-old male . presents with seizures 48 hours after running out of his Keppra, also with a subtherapeutic Dilantin level. He will be admitted to [Name of Hospital] for loading of Dilantin and Keppra and resumption of both medications orally . A review of the ED Physician Documentation, dated 3/5/23, indicated Resident 1 arrived on 3/5/23 at 1:06 a.m. via EMS. The ED physician wrote, on 3/5/23 at 1:11 a.m., The patient presents with 'More seizures' tonight per nursing home staff . He was found postictal by EMS and then said he felt like he was when have a seizure and had a full-blown seizure with O2 [oxygen] as low as 75% [normal: 95% - 100%] at the end. Was given 2.5 mg of Versed . and 3/5 4:00 [a.m.] Awaiting: History from the nursing home is helpful . it turns out they have not had Keppra since the 2nd so the patient has missed 48 hours of Keppra. They do not have any still. This is clearly at least contributing to why he is seizing. I will have to admit him since I can send him back to place the does not have the medicine to care for him. A review of the ED Nurse Documentation, dated 3/5/23 at 3:58 a.m., indicated: Contacted Watsonville Nursing Center, spoke with [name of nurse] . It was also reported to this RN by [name of nurse] that the patient has not had any of his scheduled Keppra doses (patient is prescribed 1000mg Keppra BID [meaning twice daily] for seizure prevention), reported to RN that the last dose patient received was 3/2/23 evening, and has not had any dosed since then. It was reported that the facility had ran out and they were waiting for the pharmacy to deliver more . Resident 1's clinical record indicated the resident was admitted to the hospital on [DATE] at 4:30 a.m., and discharged on 3/6/23 at 10:45 a.m. The nursing progress notes, dated 3/6/23, indicated he was re-admitted to the facility on [DATE] at approximately 2:50 p.m. A review of the hospital's Discharge summary, dated [DATE], indicated the following under Final Diagnoses: Epileptic seizure related to external causes, not intractable [untreatable], without status epilepticus [prolonged seizure lasting longer than 5 minutes or when seizures occur close together and the person doesn't recover between seizures] . Uses less medication than prescribed . Patient's unintentional underdosing of medication regimen. The History Course in the Discharge Summary indicated, .male with multiple sclerosis . Apparently they ran out of his seizure medications at the nursing facility. Seizures. Patient was admitted and received a loading dose [large dose of a medicine used to ensure a quick therapeutic response] of Dilantin and Keppra. By hospital day 2. The patient was alert and oriented and mentating at baseline. A review of the Medical Provider progress notes, written by Resident 1's attending physician (Physician A) on 3/7/23 at 9:56 p.m., indicated: Seizure d/o [disorder] . Unfortunately was out of Keppra x 2 days and had recurrent seizures. hospitalized and dilantin dose increased again. Discussed care with DON [director of nursing] re: missed medications . For now continue current doses of Dilantin and Keppra, may try to reduce Dilantin again in future. During an interview with Resident 1 on 3/17/23 at 1:27 p.m., Resident 1 stated he had been on Dilantin and Keppra for many months for seizure disorder. He stated the day he had the seizures he was very confused and did not know what was going on. He stated prior to that the nursing staff had told him they ran out of Keppra and were waiting for the pharmacy to deliver. He stated he told them he needed the medication, but they said they were still waiting for it to come. He stated he was not aware of what went on when he was at the hospital, but they put him back on the medications and sent him back. Resident 1 stated he was aware he had the seizures because he was missing a few days of Keppra. During an interview with RN A on 3/17/23 at 2:01 p.m., she confirmed she was the morning shift nurse on 3/3/23 and coded a 10 on the MAR for Resident 1's Keppra administration. She stated Code 10 meant the medication was not available, and she ordered it through the facility's computerized system. She stated she informed Resident 1 the medication was not available. She continued, I knew he had gotten it the day prior; he was stable, they didn't have the med. RN A stated she was not aware the medication was available in the facility's automatic dispensing cabinet (ADC, an automated machine where medications are stored and electronically tracked) so she could get it from there and did not inform the doctor. She confirmed she should have informed the doctor when Keppra was not available to give to the resident. RN A confirmed she was aware Resident 1 was hospitalized for seizures due to missing his Keppra when she was counseled by the DON on 3/10/23. On 3/17/23 at 2:16 p.m., the DON provided an inventory list of medications available in the facility's ADC. The list indicated the ADC contained 115 different medications including levetiracetam (Keppra) 250 mg tablets. During a telephone interview with the Pharmacist on 3/17/23 at 2:18 p.m., she stated the facility staff requested a refill for Keppra on 3/3/23 at 9:21 a.m. (this is consistent with the interview with RN A above) but it was not delivered until 3/5/23 at 4:13 p.m. (2 days later). She stated most of the refill requests were processed and delivered from a sister pharmacy in southern California, that was why it took two days to deliver. She stated, We ask [facilities] for a few days to process refills. If they need medications urgently, they give us a call to [name of pharmacy] to send with the next run. The Pharmacist reviewed the pharmacy dispensing records and stated a 30-day supply of Keppra was delivered on 1/3/23 and on 3/5/23; there were no request for and delivery in February 2023. During a concurrent interview and record review with RN B on 3/17/23 at 3:09 p.m., she stated she coded a 10 on the Keppra 5 p.m. administrations on 3/3 and 3/4/23. When asked what Code 10 meant, RN B stated, I think that was when we ran out of Keppra. She stated, I was not able to call the doctor on those days the medication was not available and could not recall whether she called the pharmacy to follow up. She stated she informed Resident 1 that they were waiting for the pharmacy to deliver. RN B reviewed the March 2023 MAR and confirmed she administered the last dose at 5 p.m. on 3/2/23, but she stated she could not remember if she ordered it. She confirmed when the medication supply was running low, the nursing staff was to re-order it 3 to 5 days ahead to allow time for the pharmacy to deliver. She also added that she was not aware the Keppra tablets were available in the ADC. RN B reviewed Resident 1's clinical record and confirmed both times, on 3/3 and 3/4/23 at 5 p.m. that she only documented on order in the nursing progress notes. During the interview above, RN B stated on the day of event, the aide called her about Resident 1 having a seizure. They ran to the resident's room, found him seizing, had him turned to his side, and probed a pillow on the wall to stop him from hitting the wall. She stated it lasted about 1 to 2 minutes, then it stopped, and he started seizing again that lasted more than 2 minutes. She called the doctor and asked to have him sent to the ER. RN B stated she was made aware Resident 1 experienced seizures because of the missing Keppra when she was counseled by the DON later that week. During a concurrent interview and record review with the DON on 3/17/23 at 3:50 p.m., the DON explained Resident 1 experienced the seizures on the weekend when he was out of Keppra for 2 days. She stated she was not aware he missed 4 doses. She stated, The nurses notified me that he went to the hospital, but I was not aware about the Keppra until I reviewed his re-admission papers the next day [after the resident returned] that's when I noticed. The DON explained, [RN A] re-ordered the Keppra on 3/3 [March 3rd] but the pharmacy delivered it on 3/5 by the time the resident was already in the hospital. The DON stated when the nursing staff ran out of the medication, they should be checking the ADC list to see if the medication is available in it; and if not, call the pharmacy to get it satellited (special delivery by a nearby pharmacy). She continued, If that's not an option, to notify the doctor to get another medication [for the resident]. She stated, They could have called the doctor to increase his Dilantin while waiting for Keppra. The DON reviewed Resident 1's clinical record and confirmed there were no documented evidence the nursing staff calling the physician or the pharmacy. The DON also said the staff should re-order the medications 3 to 5 days before they run out. She stated LVN C was not available for interview as she had tried to contact her to come in for the in-service related to this incident. During a telephone interview with Physician A on 3/17/23 at 4:25 p.m., he stated the nursing staff called him after Resident 1 had a couple of seizures on 3/4/23 around midnight, and he gave the order to send him to the ER. He stated he was not told about the missing Keppra and became aware after he pulled the hospital ER record and Discharge Summary after the resident returned from the hospital. He stated it was really concerning and that was the reason why he spoke with the DON regarding the missing medications. He stated he expected the nursing staff to call him when they did not have the Keppra. When asked if the seizure was brought on by the missing Keppra, Physician A said, Yes. He further explained that he had been working with Resident 1's neurologist (doctor who specializes in disorders that affect the brain, spinal cord, and nerves) to reduce the Dilantin due to his increased liver enzymes (a potential side effect of Dilantin); the goal was to decrease the Dilantin if his seizure could be well controlled by Keppra. He continued to explain that at first when he was called about the seizures, he thought it was due to the low Dilantin level, not until he reviewed the hospital's records, he realized it was due to the missing Keppra. When asked whether this incident could be life-threatening, Physician A responded, Any seizure is life-threatening for sure. During another interview with the DON on 3/20/23 at 9:45 a.m., she stated the expectation was for the nursing staff to call the doctor when a medication was not available. She stated it was not addressed in policy and procedures, but it is a known thing and expected that the nurse to call the doctor for missing medications or when a resident refuses medication. A review of Resident 1's Care Plan for seizure, dated 8/24/22, indicated the goal was for the resident to be/remain free of seizure activity through the review date, and to [g]ive medications as ordered. 2. A review of Resident 2's clinical record indicated she was admitted to the facility with diagnoses including muscle weakness and epilepsy. Her 1/25/23 MDS reflected she had a BIMS score of 13, indicating she had intact cognition. Resident 2's clinical record indicated a physician's order, dated 4/13/22, for Keppra Tablet 500 mg, give 1 tablet by mouth two times a day related to epilepsy. It was scheduled to be given daily at 9 a.m. and 5 p.m. A review of Resident 2's March 2023 MAR indicated LVN D entered a code 10 for the administration entry on 3/6/23 at 5 p.m. A review of the corresponding nursing progress notes, dated 3/6/23 at 5:54 p.m., indicated: Keppra Tablet 500 mg . on order. During an interview with Resident 2 on 3/20/23 at 1:55 p.m., she stated she recalled the nursing staff having told her they did not have the Keppra to give her a couple of times within the past couple of months but did not recall the exact dates. During an interview with LVN D on 3/20/23 at 3:21 p.m., she stated, The number 10 on the MAR meant we ran out of the medication. Someone ordered it. I didn't call the pharmacy [to follow up]. She also stated she did not inform the doctor when she ran out of the medication to give and confirmed she should have informed and asked the doctor for advice as the medication was for controlling the resident's seizure. A review of Resident 2's Care Plan for seizure, dated 8/23/22, indicated the goal was for the resident to remain free of seizure activity through the review date, and to [g]ive medications as ordered. A review of the facility's policy & procedures (P&P) titled Administering Medications, dated April 2019, it indicated, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame. A review of the facility's P&P titled MEDICATION ORDERING AND RECEIVING FROM PHARMACY, dated April 2008, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis . Reorder medication five days in advance of need to assure an adequate supply is on hand. Based on interview and record review, the facility failed to provide routine medications to meet the needs of residents for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 did not receive his Keppra (generic name: levetiracetam, a medication to treat seizure disorder [a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness]) for 48 hours due to the medication not being available. The nursing staff did not notify the physician when the medication was not available to give, nor did they follow up with the pharmacy to receive the medication timely. The failure resulted in Resident 1 experiencing multiple episodes of seizures, became unresponsive while being transferred to Emergency Department (ED), and was hospitalized for treatment. 2. Resident 2 did not receive her Keppra due to medication not available x 1 dose. This failure placed Resident 2 at risk to experience seizures, falls, and injuries related to seizures. Findings: According to an online publication titled Missed Medicines as a Seizure Trigger by the Epilepsy Foundation, it indicated, Missing doses of seizure medicine is the most common cause of breakthrough seizures. Missed medicines can trigger seizures in people with both well-controlled and poorly controlled epilepsy. Seizures can happen more often than normal, be more intense or develop into long seizures called status epilepticus. Status epilepticus is a medical emergency and can lead to death if the seizures aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels. (https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines; accessed 3/22/23) 1. On 3/17/23, a review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including multiple sclerosis (a disabling disease of the brain and spinal cord where immune system attacks the protective sheath [myelin] that covers nerve fibers and causes communication problems between your brain and the rest of your body), muscle weakness, abnormality of gait and mobility, and epilepsy (also called seizure disorder). A review of Resident 1's Minimum Data Set (MDS, a care area assessment and screening tool), dated 2/1/23, indicated he had a BIMS score of 12 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated his cognitive condition was moderately impaired. Further review of Resident 1's clinical record indicated a physician's order, dated 7/28/22, for Keppra 500 milligrams (mg, unit of measurement), Give 1,000 mg by mouth two times daily for seizures. The facility scheduled it to be given daily at 9 a.m. and 5 p.m. Resident 1 was also receiving Dilantin (anti-seizure medication) 100 mg, 2 capsules in the morning and 2 capsules in the evening, starting 1/29/23. A review of Resident 1's March 2023 medication administration record (MAR) indicated Keppra tablets were not administered for 48 hours, on 3/3/23 at 9 a.m. and 5 p.m. and 3/4/23 at 9 a.m. and 5 p.m., as follows: a. On 3/3/23: 9 a.m. entry: Code 10 entered by registered nurse (RN) A; 5 p.m. entry: Code 10 entered by RN B b. On 3/4/23: 9 a.m. entry: Code 10 entered by licensed vocational nurse (LVN) C; 5 p.m. entry: Code 10 entered by RN B The MAR's Chart Code indicated each number code had a different meaning, such as 1 = resident refused, 2 = resident not available. The 10 code meant Other (specify). A review of the corresponding nursing progress notes indicated the following: a. 3/3/23 at 9:21 a.m., RN A wrote Keppra Tablet 500 mg .[dosing and frequency] . on order b. 3/3/23 at 4:17 p.m., RN B wrote: Keppra Tablet 500 mg . on order c. 3/4/23 at 10 a.m., LVN C wrote: Keppra Tablet 500 mg . on order d. 3/4/23 at 4:28 p.m., RN B wrote: Keppra Tablet 500 mg . on order Further review of Resident 1's clinical record indicated the nursing progress notes, documented by RN B on 3/5/23 at 2:20 a.m., indicating: 3/4/23 at 2330, Resident started having seizures 5x [meaning 5 times] lasting more than 3 minutes. Turned resident on his side to avoid aspiration [accidental breathing in of food or fluid into the lungs]. VS [vital signs] taken. Afebrile [not feverish]. MD [physician] notified with order to send to ER [Emergency Room] for further eval[uation] . A review of the 3/5/23 Emergency Medical Services (EMS) Prehospital Care Report w/o [without] Attachments, provided by the hospital, indicated: Responded to seizures. Upon arrival pt [patient] found lying left lateral position . postictal [period of time immediately following a seizure] . Per staff pt has been witnessed to have multiple seizures starting at approx. 23:45 tonight. Per staff pt has a history of seizures . Pt is noted to have shaking of extremities and pt reports impending seizure. Pt is noted to have a full-body generalized seizure lasting approx. 2 minutes. Pt administered 2.5 mg Versed [medication to treat seizures] IM [intramuscularly, meaning deep muscle injection] . Pt is noted to be unresponsive . During transport pt remained altered and unstable. At hospital pt moved to Emergency Department . A review of the acute care hospital's History and Physical (document that provides concise information about a patient's history and exam findings at the time of admission), date of service 3/5/23 at 4:55 a.m., indicated the hospital received Resident 1 for Chief Complaint of seizure. Under History of Present Illness (HPI), a hospital's physician wrote, [Age of resident] year-old male, institutionalized due to multiple sclerosis, presents with seizures. He has a longstanding seizure disorder for which he takes Dilantin and Keppra. The patient had 2 seizures in the nursing home for which 911 was called. He seized again for paramedics and they gave him intramuscular Versed at least twice. Seizure. When the patient got to the emergency room. However he was postictal and unresponsive. Dilantin level was subtherapeutic [lower than normal range] and it turns out the nursing home ran out of Keppra 48 hours ago. Under Plan, the H&P indicated, [Age] year-old male . presents with seizures 48 hours after running out of his Keppra, also with a subtherapeutic Dilantin level. He will be admitted to [Name of Hospital] for loading of Dilantin and Keppra and resumption of both medications orally . A review of the ED Physician Documentation, dated 3/5/23, indicated Resident 1 arrived on 3/5/23 at 1:06 a.m. via EMS. The ED physician wrote, on 3/5/23 at 1:11 a.m., The patient presents with 'More seizures' tonight per nursing home staff . He was found postictal by EMS and then said he felt like he was when have a seizure and had a full-blown seizure with O2 [oxygen] as low as 75% [normal: 95% - 100%] at the end. Was given 2.5 mg of Versed . and 3/5 4:00 [a.m.] Awaiting: History from the nursing home is helpful . it turns out they have not had Keppra since the 2nd so the patient has missed 48 hours of Keppra. They do not have any still. This is clearly at least contributing to why he is seizing. I will have to admit him since I can send him back to place the does not have the medicine to care for him. A review of the ED Nurse Documentation, dated 3/5/23 at 3:58 a.m., indicated: Contacted Watsonville Nursing Center, spoke with [name of nurse] . It was also reported to this RN by [name of nurse] that the patient has not had any of his scheduled Keppra doses (patient is prescribed 1000mg Keppra BID [meaning twice daily] for seizure prevention), reported to RN that the last dose patient received was 3/2/23 evening, and has not had any dosed since then. It was reported that the facility had ran out and they were waiting for the pharmacy to deliver more . Resident 1's clinical record indicated the resident was admitted to the hospital on [DATE] at 4:30 a.m., and discharged on 3/6/23 at 10:45 a.m. The nursing progress notes, dated 3/6/23, indicated he was re-admitted to the facility on [DATE] at approximately 2:50 p.m. A review of the hospital's Discharge summary, dated [DATE], indicated the following under Final Diagnoses: Epileptic seizure related to external causes, not intractable [untreatable], without status epilepticus [prolonged seizure lasting longer than 5 minutes or when seizures occur close together and the person doesn't recover between seizures] . Uses less medication than prescribed . Patient's unintentional underdosing of medication regimen. The History Course in the Discharge Summary indicated, .male with multiple sclerosis . Apparently they ran out of his seizure medications at the nursing facility. Seizures. Patient was admitted and received a loading dose [large dose of a medicine used to ensure a quick therapeutic response] of Dilantin and Keppra. By hospital day 2. The patient was alert and oriented and mentating at baseline. A review of the Medical Provider progress notes, written by Resident 1's attending physician (Physician A) on 3/7/23 at 9:56 p.m., indicated: Seizure d/o [disorder] . Unfortunately was out of Keppra x 2 days and had recurrent seizures. hospitalized and dilantin dose increased again. Discussed care with DON [director of nursing] re: missed medications . For now continue current doses of Dilantin and Keppra, may try to reduce Dilantin again in future. During an interview with Resident 1 on 3/17/23 at 1:27 p.m., Resident 1 stated he had been on Dilantin and Keppra for many months for seizure disorder. He stated the day he had the seizures he was very confused and did not know what was going on. He stated prior to that the nursing staff had told him they ran out of Keppra and were waiting for the pharmacy to deliver. He stated he told them he needed the medication, but they said they were still waiting for it to come. He stated he was not aware of what went on when he was at the hospital, but they put him back on the medications and sent him back. Resident 1 stated he was aware he had the seizures because he was missing a few days of Keppra. During an interview with RN A on 3/17/23 at 2:01 p.m., she confirmed she was the morning shift nurse on 3/3/23 and coded a 10 on the MAR for Resident 1's Keppra administration. She stated Code 10 meant the medication was not available, and she ordered it through the facility's computerized system. She stated she informed Resident 1 the medication was not available. She continued, I knew he had gotten it the day prior; he was stable, they didn't have the med. RN A stated she was not aware the medication was available in the facility's automatic dispensing cabinet (ADC, an automated machine where medications are stored and electronically tracked) so she could get it from there and did not inform the doctor. She confirmed she should have informed the doctor when Keppra was not available to give to the resident. RN A confirmed she was aware Resident 1 was hospitalized for seizures due to missing his Keppra when she was counseled by the DON on 3/10/23. On 3/17/23 at 2:16 p.m., the DON provided an inventory list of medications available in the facility's ADC. The list indicated the ADC contained 115 different medications including levetiracetam (Keppra) 250 mg tablets. During a telephone interview with the Pharmacist on 3/17/23 at 2:18 p.m., she stated the facility staff requested a refill for Keppra on 3/3/23 at 9:21 a.m. (this is consistent with the interview with RN A above) but it was not delivered until 3/5/23 at 4:13 p.m. (2 days later). She stated most of the refill requests were processed and delivered from a sister pharmacy in southern California, that was why it took two days to deliver. She stated, We ask [facilities] for a few days to process refills. If they need medications urgently,[TRUNCATED]