**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled residents (Resident #127) who experienced a change in condition that required a hospitalization, the facility failed to ensure that readmission physician's orders were transcribed accurately resulting in the resident missing 12 doses of medications (6 days) and not receiving the accurate dosages of another medication culminating in the resident being re-hospitalized . These failures resulted in the finding of Immediate Jeopardy. The findings include: Resident #127 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, chronic bronchitis, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, chronic kidney disease (stage 3) and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #127 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, toilet use and personal hygiene, was independent with eating, had no range of motion deficits, utilized a wheelchair and walker as mobility devices and received anticoagulant medication. The MDS further noted the resident's diagnoses included coronary artery disease, pulmonary embolism and respiratory failure. The care plan initiated in February of 2022 identified Resident #127 had impaired cognitive function related to dementia with interventions that included observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed A reportable event report dated 4/28/22 identified that upon Resident #127's re-admission to the facility on 4/19/22 the following medications were not transcribed into the electronic medical record and thus not included on the medication administration record (MAR): Eliquis, Metformin, and Metoprolol Tartrate and Prednisone was not transcribed properly. The report identified the event type as a medication error of clinical significance and noted the resident had been hospitalized on [DATE] and was expected to return to the facility on 4/30/22. The hospital Discharge summary dated [DATE] identified Resident #127 was admitted to the hospital on [DATE] for the chief complaint of shortness of breath (sudden onset of respiratory distress and change in mental status after receiving Rocephin (antibiotic) for cellulites. The discharge summary contained a medication list with all current and recommended medications. The list included an order for Prednisone (steroid) 20 mg by mouth every morning with breakfast for two days and then 10 mg by mouth for three days, Metformin (anti-diabetic medication) 500mg by mouth two times per day with meals, Metoprolol Tartrate (beta blocker used to treat high blood pressure, angina, heart failure and it may lower the risk of death after a heart attack) 25 mg by mouth every twelve hours and Eliquis (used to prevent serious blood clots from forming due to atrial fibrillation or surgery) 5mg twice per day. Review of the admission physician's orders located in the electronic medical record dated 4/19/22 failed to reflect that the orders for Metoprolol Tartrate, Metformin, and Eliquis were transcribed (entered into the electronic medical record system). Further review identified the order for Prednisone was entered incorrectly. The order was written as Prednisone 20mg once per day for three days then stop until 4/25/22 and Prednisone 10mg give two tablets by mouth one time per day for SOB (shortness of breath) for two days. Review of the medication administration record (MAR) for April identified Resident #127 was administered 20 mg of Prednisone on the 20, 21, 23, 24 and 25th. The MAR indicated that Prednisone was not administered on the 22nd. According to the hospital discharge summary Resident #127 should have received 10mg on April 22, 23 and 24th. The MAR did not contain the orders for the Metformin, Metoprolol Tartrate or the Eliquis resulting in the medications not being administered between 4/19/22 and 4/25/22. The nurse's note dated 4/19/22 at 6:11 PM written by RN #4 identified that Resident #127 arrived at the facility a little after 5:00 PM and medications were reviewed and verified with Physician #1. The nurse's note dated 4/21/22 at 3:51 PM identified Resident #127 was alert and confused per baseline. It further noted he/she was on 3 liters of oxygen via nasal cannula, lung sounds clear to auscultation, no cardiac or respiratory distress and no indication of pain or discomfort. The nurse's note dated 4/22/22 at 9:52 PM identified Resident #127 was on the 3rd day post readmission, denied pain, appetite good, blood pressure: 138/70, pulse: 76, respirations: 20, oxygen saturation level noted to be 98% on oxygen. The nurse's note dated 4/25/22 at 9:00 AM written by RN #5 identified Resident #127 had altered mental status with response to painful stimuli. The DNS was immediately notified, and a full body audit was completed. Vital signs were taken and reported to Physician #1 who ordered that the resident be sent to the hospital. The hospital Discharge summary dated [DATE] identified that that the resident was admitted to the hospital on [DATE] with the chief complaint of unresponsiveness. It further noted the final diagnoses on discharge as acute on chronic hypoxic respiratory failure, COPD exacerbation, acute on chronic diastolic heart failure exacerbation, acute metabolic encephalopathy, questionable atrial fibrillation with lots of artifact, hypomagnesemia and hypokalemia likely diuresis related, history of bilateral pulmonary embolism with secondary hypercoagulable state on Eliquis, COPD on 2 to 3 liters admitted on 6 liters and back down to 3 liters, diabetes mellitus type 2, hypertension, hypothyroidism and dementia. The summary also noted that the resident had a moderate left pleural effusion. Further review of the discharge summary identified that during the hospital course the resident was diuresed with intravenous Lasix (diuretic) 40 mg twice daily for the heart failure. The resident was admitted to the telemetry unit. Interview on 5/10/22 at 9:30 AM with the DNS, Corporate Clinical Director and MDS nurse identified that during a record review the MDS nurse identified that the resident was not receiving Eliquis, which the resident had been taking prior to 4/19/22, this discrepancy prompted an overall medication review which resulted in the discovery that the Eliquis along with the Metformin and the Metoprolol Tartrate had been missed for 6 days for a total of 12 missed doses of each medication. The review also identified that the incorrect dose of Prednisone had been administered for three days with one missed dose (4/22/22). Interview on 5/11/2022 at 12:40 PM with RN# 5 identified that on 4/25/22 she greeted Resident #127 and the resident only opened his/her eyes when normally he/she would respond verbally. RN# 5 identified that she performed a mild sternal rub and the resident mildly groaned and turned away from the nurse. She further identified that since the resident is always engaging, she notified the DNS who assessed Resident #127, Physician #1 was notified, and an order given to send the resident to the hospital to be evaluated. The clinical hospital transfer form also completed by RN# 5 identified the resident's vital signs as follows, blood pressure 156/70, respirations 26, temperature 98.2, oxygen saturation 99% on 3liters of oxygen per minute, heart rate 50 and blood glucose level 134 mg/dl (levels of 80mg/dl to 130mg/dl is the normal range for a type 2 diabetic before the consumption of a meal). Interview on 5/11/2022 at 2:00 PM with RN #4 identified upon Resident #127's readmission on [DATE], she reviewed and verified the medication orders with Physician #1. RN #4 further identified that she worked 7:00 AM to 7:00 PM on 4/19/22 and although she confirmed the orders with Physician #1, she noted that the orders were electronically entered into the resident's electronic medical record by RN #7 (RN #7 worked 7:00 PM to 7:00 AM on 4/19/22). Interview on 5/11/2022 at 2:34 PM with Physician #1 identified that upon Resident #127's readmission to the facility, medications were approved as recommended by the hospital. He further noted that it was unfortunate that the resident had not received all of the ordered medications and was upset that the medication errors occurred. In addition, he indicated that he did not feel that the failure to administer the ordered medications for six days contributed to the resident being re-hospitalized on [DATE]. Physician #1 noted that the resident had a COPD exacerbation and the Metformin has been known to have a lasting effect, the resident's blood pressures were normal and there was no evidence of clotting. In addition, he acknowledged that Resident #127 was administered higher doses of Prednisone than he/she should have but also felt that this did not have an adverse effect on the resident. Physician #1 noted that any medications that are ordered should be administered. Interview on 5/11/2022 at 3:00 PM with the DNS identified that prior to the discovery of the medication errors/omissions, the facility did not have a policy in place that addressed the admission/readmission process but noted that the practice involves the orders being entered into the EMR and a chart check completed to confirm the orders. The DNS further identified that the unit manager/nursing supervisor or RN on duty on the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shifts perform the chart check. The DNS could not provide any documentation that a chart check had been performed for Resident #127 when he/she was readmitted to the facility on [DATE]. Interview on 5/12/2022 at 7:40 AM with RN #7 identified she could not recall entering the physician's orders into the EMR on the evening of 4/19/2022, but review of the electronic medical record identified that RN #7 entered the medications into the system. A second interview on 5/12/2022 at 12:55 PM with RN #4 identified that she utilized a cell phone to scan the discharge medication summary forms to Physician #1 and received a text message back from Physician #1 that read meds look good. In addition, RN #4 was able to indicate on her cell phone what she had sent to the physician and the message that he sent to her indicating an approval of the orders. A review of the scanned forms matched the discharge medication summary forms. Following the discovery of the medication errors, the facility initiated a new protocol dated 4/29/2022 that identified the following: * Upon admission and readmission, the discharge summary and W-10 will be compared for any discrepancies. If it is a readmission, the orders will also be compared to the resident's orders form the prior admission. All orders will then be reviewed with the MD or APRN with discrepancies noted and clarified and documented in a nurses note. * Once medications are reconciled and orders obtained, orders are to be transcribed into the point click care (PCC . electronic medical record system) and checked by a second nurse immediately following transcription. * The process is to be documented on the admission Checklist * The admission Checklist will be completed for all new admissions/ readmissions and verified by a second nurse. * The resident's record will be reviewed again by Nursing Management and documented on the admission checklist. * When transcribing orders, be sure to verify the correct medication, dose, route and frequency as well as ensuring that it is transcribed into PCC in a manner that displays on the MAR or TAR (treatment administration record) and has a schedule A review of the facility's corrective action plan on 5/12/22 at 4:00 PM included a review of the records of all twelve residents admitted to the facility since 4/19/22. Licensed staff were educated and re-educated on the protocol to have two nurses review the medication reconciliation and transcription process for new admissions and readmissions with an administrative nurse performing a third check of the records. An audit of the newly admitted and readmitted resident records from 4/19/22 identified no other irregularities. The facility failed to ensure critical medications were transcribed correctly and administered to Resident #127 as ordered for a period of six days resulting in the omission of a total of 36 doses of the combined omitted medications of Metoprolol Tartrate, Metformin, and Eliquis, in addition, the wrong Prednisone dose was administered for three days and one day it was omitted all together. These failures resulted in a finding of Immediate Jeopardy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for one of three sampled resident (Resident #127) reviewed for a change in condition, the facility failed to ensure the resident was free of significant medication errors related to critical medications (Metformin, Metoprolol, Eliquis) not administered for six days for a total of 36 mixed doses as well as the incorrect dosage of Prednisone administered for a total of three days. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #127 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, chronic bronchitis, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, chronic kidney disease (stage 3) and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #127 had severe cognitive impairment, required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, toilet use and personal hygiene, was independent with eating, had no range of motion deficits, utilized a wheelchair and walker as mobility devices and received anticoagulant medication. The MDS further noted the resident's diagnoses included coronary artery disease, pulmonary embolism and respiratory failure. The care plan initiated in February of 2022 identified Resident #127 had impaired cognitive function related to dementia with interventions that included observe and evaluate types of changes in cognitive status, e.g., confusion, orientation, forgetfulness, decision making ability, ability to express self, ability to understand others, impulsivity, mental status and notify physician as needed A reportable event report dated 4/28/22 identified that upon Resident #127's re-admission to the facility on 4/19/22 the following medications were not transcribed into the electronic medical record and thus not included on the medication administration record (MAR): Eliquis, Metformin, and Metoprolol Tartrate and Prednisone was not transcribed properly. The report identified the event type as a medication error of clinical significance and noted the resident had been hospitalized on [DATE] and was expected to return to the facility on 4/30/22. The hospital Discharge summary dated [DATE] identified Resident #127 was admitted to the hospital on [DATE] for the chief complaint of shortness of breath (sudden onset of respiratory distress and change in mental status after receiving Rocephin (antibiotic) for cellulites. The discharge summary contained a medication list with all current and recommended medications. The list included an order for Prednisone (steroid) 20 mg by mouth every morning with breakfast for two days and then 10 mg by mouth for three days, Metformin (anti-diabetic medication) 500mg by mouth two times per day with meals, Metoprolol Tartrate (beta blocker used to treat high blood pressure, angina, heart failure and it may lower the risk of death after a heart attack) 25 mg by mouth every twelve hours and Eliquis (used to prevent serious blood clots from forming due to atrial fibrillation or surgery) 5mg twice per day. Review of the admission physician's orders located in the electronic medical record dated 4/19/22 failed to reflect that the orders for Metoprolol Tartrate, Metformin, and Eliquis were transcribed (entered into the electronic medical record system). Further review identified the order for Prednisone was entered incorrectly. The order was written as Prednisone 20mg once per day for three days then stop until 4/25/22 and Prednisone 10mg give two tablets by mouth one time per day for SOB (shortness of breath) for two days. Review of the medication administration record (MAR) for April identified Resident #127 was administered 20 mg of Prednisone on the 20, 21, 23, 24 and 25th. The MAR indicated that Prednisone was not administered on the 22nd. According to the hospital discharge summary Resident #127 should have received 10mg on April 22, 23 and 24th. The MAR did not contain the orders for the Metformin, Metoprolol Tartrate or the Eliquis resulting in the medications not being administered between 4/19/22 and 4/25/22. The nurse's note dated 4/19/22 at 6:11 PM written by RN #4 identified that Resident #127 arrived at the facility at 5:00 PM and medications were reviewed and verified with Physician #1. The nurse's note dated 4/21/22 at 3:51 PM identified Resident #127 was alert and confused per baseline. It further noted he/she was on 3 liters of oxygen via nasal cannula, lung sounds clear to auscultation, no cardiac or respiratory distress and no indication of pain or discomfort. The nurse's note dated 4/22/22 at 9:52 PM identified Resident #127 was on the 3rd day post readmission, denied pain, appetite good, blood pressure: 138/70, pulse: 76, respirations: 20, oxygen saturation level noted to be 98% on oxygen. The nurse's note dated 4/25/22 at 9:00 AM written by RN #5 identified Resident #127 had altered mental status with response to painful stimuli. The DNS was immediately notified, and a full body audit was completed. Vital signs were taken and reported to Physician #1 who ordered that the resident be sent to the hospital. The hospital Discharge summary dated [DATE] identified that that the resident was admitted to the hospital on [DATE] with the chief complaint of unresponsiveness. It further noted the final diagnoses on discharge as acute on chronic hypoxic respiratory failure, COPD exacerbation, acute on chronic diastolic heart failure exacerbation, acute metabolic encephalopathy, questionable atrial fibrillation with lots of artifact, hypomagnesemia and hypokalemia likely diuresis related, history of bilateral pulmonary embolism with secondary hypercoagulable state on Eliquis, COPD on 2 to 3 liters admitted on 6 liters and back down to 3 liters, diabetes mellitus type 2, hypertension, hypothyroidism and dementia. The summary also noted that the resident had a moderate left pleural effusion. Further review of the discharge summary identified that during the hospital course the resident was diuresed with intravenous Lasix (diuretic) 40 mg twice daily for the heart failure. The resident was admitted to the telemetry unit (patients who suffer from heart disease, heart failure and complications associated with cardiac conditions are placed on the telemetry unit for close monitoring). Interview on 5/10/22 at 9:30 AM with the DNS, Corporate Clinical Director and MDS nurse identified that during a record review the MDS nurse identified that the resident was not receiving Eliquis, which the resident had been taking prior to 4/19/22.This discrepancy prompted an overall medication review which resulted in the discovery that the Eliquis along with the Metformin and the Metoprolol Tartrate had been missed for 6 days for a total of 12 missed doses of each medication. The review also identified that the incorrect dose of Prednisone had been administered for three days with one missed dose (4/22/22). Interview on 5/11/2022 at 12:40 PM with RN# 5 identified that on 4/25/22 she greeted Resident #127 and the resident only opened his/her eyes when normally he/she would respond verbally. RN# 5 identified that she performed a mild sternal rub and the resident mildly groaned and turned away from the nurse. She further identified that since the resident is always engaging, she notified the DNS who assessed Resident #127, Physician #1 was notified, and an order given to send the resident to the hospital to be evaluated. The clinical hospital transfer form also completed by RN# 5 identified the resident's vital signs as follows, blood pressure 156/70, respirations 26, temperature 98.2, oxygen saturation 99% on 3liters of oxygen per minute, heart rate 50 and blood glucose level 134 mg/dl (levels of 80mg/dl to 130mg/dl is the normal range for a type 2 diabetic before the consumption of a meal). Interview on 5/11/2022 at 2:00 PM with RN #4 identified upon Resident #127's readmission on [DATE], she reviewed and verified the medication orders with Physician #1. RN #4 further identified that she worked 7:00 AM to 7:00 PM on 4/19/22 and although she confirmed the orders with Physician #1, she noted that the orders were electronically entered into the resident's electronic medical record by RN #7 (RN #7 worked 7:00 PM to 7:00 AM on 4/19/22). Interview on 5/11/2022 at 2:34 PM with Physician #1 identified that upon Resident #127's readmission to the facility, medications were approved as recommended by the hospital. He further noted that it was unfortunate that the resident had not received all of the ordered medications and was upset that the medication errors occurred. In addition, he indicated that he did not feel that the failure to administer the ordered medications for six days contributed to the resident being re-hospitalized on [DATE]. Physician #1 noted that the resident had a COPD exacerbation and the Metformin has been known to have a lasting effect, the resident's blood pressures were normal and there was no evidence of clotting. In addition, he acknowledged that Resident #127 was administered higher doses of Prednisone than he/she should have but also felt that this did not have an adverse effect on the resident. Physician #1 noted that any medications that are ordered should be administered. Interview on 5/11/2022 at 3:00 PM with the DNS identified that prior to the discovery of the medication errors/omissions, the facility did not have a policy in place that addressed the admission/readmission process but noted that the practice involves the orders being entered into the EMR and a chart check completed to confirm the orders. The DNS further identified that the unit manager/nursing supervisor or RN on duty on the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shifts perform the chart check. The DNS could not provide any documentation that a chart check had been performed for Resident #127 when he/she was readmitted to the facility on [DATE]. Interview on 5/12/2022 at 7:40 AM with RN #7 identified she could not recall entering the physician's orders into the EMR on the evening of 4/19/2022, but review of the electronic medical record identified that RN #7 entered the medications into the system. A second interview on 5/12/2022 at 12:55 PM with RN #4 identified that she utilized a cell phone to scan the discharge medication summary forms to Physician #1 and received a text message back from Physician #1 that read meds look good. In addition, RN #4 was able to indicate on her cell phone what she had sent to the physician and the message that he sent to her indicating an approval of the orders. A review of the scanned forms matched the discharge medication summary forms. Interview on 5/12/2022 at 3:20 PM with the Pharmacy Consultant indicated Eliquis has a half-life of 12 hours resulting in the medication having cleared Resident #127's system in a 48 hour period, meaning after 4/21/22 there was no anticoagulant in the resident's system, which could have resulted in the resident forming a blood clot/pulmonary embolism. According to information contained on the website healthfully.com once a diabetic stops taking Metformin, the blood glucose levels will increase which can have an adverse impact on overall health. According to the website Drugs.com abrupt discontinuation of Metoprolol Tartrate can exacerbate angina and may increase the risk of a heart attack; it notes that the dose should be reduce gradually over a few weeks as instructed by a physician. The Drugs.com website further identified that the lowest effective dose should always be used because it can increase the blood pressure. Following the discovery of the medication errors, the facility initiated a new protocol dated 4/29/2022 that identified the following: * Upon admission and readmission, the discharge summary and W-10 will be compared for any discrepancies. If it is a readmission, the orders will also be compared to the resident's orders from the prior admission. All orders will then be reviewed with the MD or APRN with discrepancies noted and clarified and documented in a nurses note. * Once medications are reconciled and orders obtained, orders are to be transcribed into the point click care (PCC . electronic medical record system) and checked by a second nurse immediately following transcription. * The process is to be documented on the admission Checklist * The admission Checklist will be completed for all new admissions/ readmissions and verified by a second nurse. * The resident's record will be reviewed again by Nursing Management and documented on the admission checklist. * When transcribing orders, be sure to verify the correct medication, dose, route and frequency as well as ensuring that it is transcribed into PCC in a manner that displays on the MAR or TAR (treatment administration record) and has a schedule The facility failed to ensure critical medications were administered to Resident #127 as ordered for a period of six days resulting in the omission of a total of 36 doses of the combined omitted medications of Metoprolol Tartrate, Metformin, and Eliquis, in addition, the wrong Prednisone dose was administered for three days and one day it was omitted all together culminating in the resident being hospitalized for acute on chronic hypoxic respiratory failure, COPD exacerbation, acute on chronic diastolic heart failure exacerbation, acute metabolic encephalopathy, questionable atrial fibrillation as well as a moderate left pleural effusion. These failures resulted in a finding of Immediate Jeopardy A review of the facility's corrective action plan on 5/12/22 at 4:00 PM included a review of the records of all twelve residents admitted to the facility since 4/19/22. Licensed staff were educated and re-educated on the protocol to have two nurses review the medication reconciliation and transcription process for new admissions and readmissions with an administrative nurse performing a third check of the records. An audit of the newly admitted and readmitted resident records from 4/19/22 identified no other irregularities. The Immediate Jeopardy was removed on 5/12/22.