**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review, policy review, physician, pharmacy, and staff interviews, the facility failed to have a system in place to ensure medication orders were received from the pharmacy. This failure resulted in a physician ordered diuretic medication not being administered for 1 of 3 residents sampled (Resident #42). Resident #42 went into fluid overload (a condition where there is too much fluid volume in the body that can cause high blood pressure, swelling, and heart problems) and atrial fibrillation (irregular and often very rapid heart rhythm) which required direct admission to the hospital therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The Iowa Department of Inspections, Appeals and Licensing informed the facility of the Immediate Jeopardy (IJ) that began as of 8/02/23. The Facility Staff removed the IJ on August 8, 2023 through the following actions: a. The Administrator and Regional Director of Operations provided education 8/04/23 to the Director of Nursing (DON) regarding if multiple residents are seen during rounds, the new physician orders are to be faxed per individual resident to the pharmacy allowing the DON to better track submission and determine if the fax was transmitted to the pharmacy. b. The DON provided verbal education to Staff G, Registered Nurse (RN) on 8/07/23 regarding medication administration followed by medication administration competency 8/08/23. c. The DON provided all staff nurses with education on the medication administration policy and pharmacy services policy on 8/08/23; followed by observation of medication administration competency as each nurse reports for duty. The scope lowered from a J to a G at the time of the survey after ensuring the facility implemented the education on the medication administration and pharmacy services policies, as well as observation of nursing medication skills for competency. The facility identified a census of 44 residents. Findings include: Resident #42 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required limited assistance with bed mobility, transfer, walking in the room, corridor, and on/off the unit, toilet use, dressing, and personal hygiene. The MDS listed diagnoses of aftercare for hip fracture, peripheral vascular disease, atrioventricular block first degree (a heart rhythm disorder that causes the heart to beat more slowly than it should. It's caused by communication problems within the heart's electrical conduction system. For some people, the condition doesn't cause symptoms; for others, it may be life-threatening) and hypertension. The resident received physical and occupational therapy services and expected to discharge back to the community. A Progress Note, Health Status Note, dated 7/31/23 at 1:37 p.m. documented by Staff G, Registered Nurse (RN) detailed Resident #42 complained of increased shortness of breath with activity/exertion, exhibited 3-4+ edema (swelling), non-pitting to bilateral lower extremities, and exhibited abdominal distention. Vital Signs showed: temperature -98.2, pulse - 83, respirations - 18, blood pressure - 130/63, and oxygen saturation of 94% on room air. History of: hypertensive kidney disease with stage 1 through stage 4, sleep apnea, and polyneuropathy. A call was placed to the physician by the Director of Nursing (DON). The information had also been faxed and the facility awaited further orders. A Progress Note, Health Status Note dated 7/31/2023 at 8:39 p.m. written by Staff I, Licensed Practical Nurse (LPN) documented Resident #42 did not want to eat too much and refused his health shake. He complained of being full. A fax was sent out to the physician and the office had been called. The facility did not receive any call back. The Nursing Home Visit note dated 8/01/23 documented by the Advanced Registered Nurse Practitioner (ARNP) documented the ARNP saw the resident for edema of his legs, thighs and buttocks. Resident #42 reported his abdomen quite big. The Visit Note detailed Resident #42 weighed 181# (pounds) upon admission and the weight today (8/01/23) is 192#. He also exhibited scrotal edema. Resident #42 physical examination revealed the following: a. Vitals signs - weight 192#, blood pressure 112/68, temperature 98.1 degrees Fahrenheit (F), pulse 89 beats per minutes (BPM), respirations 18 breaths per minute (BPM), oxygen saturation range between 94% (percent) to 98% on room air. b. Lungs - clear, but appear somewhat diminished in the bases bilaterally. c. Extremities - some edema in the hips, thighs and lower extremities bilaterally, probably 1-2+ and pitting (pitting edema occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit, or indentation, will remain). The Visit Note Assessment and Plan directed to start him on Lasix 20 milligrams (mg) every day x 4 days, start daily and start daily weights. A Communication with the Physician Note dated 8/1/2023 3:51 p.m. written by the DON detailed the ARNP had been at the facility for routine rounds. They discussed Resident #42 weight, bloated feeling in the abdomen, and scrotal edema. The Resident reported increased shortness of breath when lying flat. The Facility notified the ARNP of the mutual decision to hold the bilateral lower extremity wraps until seen today. Orders received to: (1) continue holding the leg wraps until the weights reviewed by the ARNP on 8/3/23; (2) new order for Lasix 20 mg by mouth daily for 4 days; (3) daily weight before breakfast with no call for parameters for review by provider; (4) continue with plan for the resident to be seen by physician on 8/4/2023 for a 30-day visit and discharge to the assisted living. The resident's primary nurse updated and pharmacy faxed. The resident's son updated via telephone on visit, new orders, and the plan of care. An Order Summary Report signed by the ARNP and noted by the DON on 8/01/23 documented a physician order for Lasix 20 mg by mouth every day x 4 days, daily weights, and hold the leg wraps until 8/03/23. A MDS Note dated 8/1/2023 at 6:33 p.m. written by Social Services documented Resident #42 reported swelling in his legs caused him to have difficulty sleeping daily, which in turn caused him to feel tired. A Health Status Note, Progress Note dated 8/1/2023 at 9:59 p.m. written by Staff I, Licensed Practical Nurse (LPN) documented Resident 42's pulse as high and his oxygen saturation at 88 percent (normal oxygen saturation for elderly over the age of 70 is around 95%). Resident #42's August 2023 Treatment Administration Record (TAR) documented the following daily weights: a. 8/02/23 185 pounds b. 8/03/23 193 pounds c. 8/04/23 197 pounds The August 2023 Medication Administration Record (MAR) documented an order for Lasix Oral Tablet 20 mg, give 1 tablet by mouth in the morning for weight increase for 4 days at 7:00 a.m. The MAR detailed the following: a. 8/02/23 Lasix medication signed out as administered by Staff G. b. 8/03/23 Lasix medication signed out as administered by Staff G. c. 8/04/23 Lasix medication documented as a 5 indicating to hold/see progress notes by Staff H, LPN. A Communication with Physician Progress Note dated 8/03/23 at 4:36 p.m. transcribed by the DON documented the ARNP at the facility for routine rounds. Resident #42's recent weights and vital signs were reviewed. The ARNP had been informed the resident reported improved symptoms of lower abdominal bloating, discomfort, and shortness of breath when lying flat since administration of oral Lasix. The ARNP reviewed the last lab results and new orders obtained to draw a basic metabolic profile (BMP is a lab test that measures eight different substances in your blood. It provides important information about the body's chemical balance and metabolism) in the morning 8/04/23. Continue with plan for the resident to be seen by the physician on 8/04/2023 during routine rounds. Continue with plan for discharge to assisted living after the visit. Discussed plan to obtain orders for outpatient physical and occupational therapies. The physician to determine if occupational therapy needed for activities of daily living (ADL's) and lymphedema management needed. Also discussed need for the resident to have a follow up visit in 1 week. Son to be notified after the physician visits. A Health Status Note, Progress Note dated 8/3/2023 at 5:00 p.m. written by Staff J, RN, documented Resident #42 reported occasional shortness of breath when lying in bed and non-pitting swelling noted to his bilateral lower legs. An Administrative Note dated 8/04/23 at 9:37 a.m. written by Staff H documented the Lasix Oral Tablet 20 mg as being held as the resident would see the provider that morning. A Health Status Note, Progress Note dated 8/4/2023 at 1:17 p.m. documented by Staff H detailed Resident #42 had been seen on rounds by the physician. The physician discovered Resident #42 was in atrial fibrillation and wanted the Resident admitted to the hospital for telemetry monitoring. An eInteract Change in Condition Evaluation V4.2 Form dated 8/04/23 at 1:36 p.m. by Staff H documented resident #42 had new or worsening edema (swelling) and atrial fibrillation per the physician's rounds noting the change started on 8/04/23. The Evaluation detailed Resident #42 had a new irregular pulse at 105 beats per minute, swelling, and persistent bilateral edema. The Evaluation documented the physician had discovered atrial fibrillation and wanted the resident admitted for telemetry monitoring. An eInteract Transfer V4.1 Form dated 8/04/23 at 2:00 p.m. completed by Staff H documented Resident #42 transferred out direct admit per the physician's rounds to the local hospital. The Transfer Form documented Resident #42's vital signs: temperature 98.2 degrees F, pulse 105 BPM, respirations 17 BPM, blood pressure 151/97 and oxygen saturation of 97 percent (%). The 8/04/23 Clinical Note documented by the Physician documented Resident #42 was slated to discharge to assisted living today, but over the past few days developed significant amounts of swelling. He had been seen on Wednesday by the ARNP who recommended treatment with oral Lasix. However, he did not receive that at the nursing home and his swelling had not improved and his breathing had gotten somewhat worse. He is in atrial fibrillation upon exam with a rate in the low 100's. His baseline (heart) rate is about 70 (BPM). At this point given the amount of edema that he has and atrial fibrillation, recommended he be admitted to the hospital for IV diuresis (Intravenous (IV) loop diuretics play an important role in the treatment of decompensated heart failure), telemetry a technique that enables continuous tracking of the heartbeat. It measures the electrical activity of the heart. Doctors use telemetry systems to check for abnormal patterns that indicate serious heart problems), echocardiogram (EKG) an ultrasound test that checks the structure and function of your heart), labs, and better control of his atrial fibrillation. He is to be a direct admit to the hospital, bypassing the emergency room. The 8/04/23 History and Physical (H+P) for the hospital documented by the Physician documented Resident #42 had planned to discharge today to the assisted living, however, that changed when he starting having more swelling a few days ago. He had been seen by the ARNP who started him on Lasix. Unfortunately, a medication error lead to the medicine not being administered. He had a B-type natriuretic peptide (BNP lab) today which was unchanged from prior, though that was largely probably because he did not actually get his diuresis. He reports that he is feeling more short of breath. He feels like the fluid is extending into his abdomen and that he is more distended. He also has some scrotal edema along with a rash in his groin. Resident #42 reported he has never had swelling like this before. The H+P Physical Exam documented the following: a. Blood pressure 142/70, pulse 103, temperature 98.6 degrees, respirations 20, oxygen saturation 97% b. Cardiovascular - tachycardia (tachycardia means that your heart is beating much faster than normal, usually more than 100 beats per minute) present, rhythm irregular. c. Musculoskeletal - right and left lower legs with edema present. 3+ pitting edema of bilateral lower extremities extending into the abdomen and scrotum. The 8/04/23 BNP lab (A B-type natriuretic peptide (BNP) test gives the provider information about how the heart is working. This blood test measures the levels of a protein called BNP in the bloodstream. When the heart has to work harder to pump blood, it makes more BNP. Higher levels of BNP can be a sign of heart failure) showed a value of 8,313, high level (normal range is 0-450). The Assessment and Plan documented a diagnosis of congestive heart failure, unspecified heart failure chronicity. Resident now with significant weight gain, increasing bilateral edema up to his scrotum, orthopnea (shortness of breath when lying flat), and shortness of breath. Most likely in fluid overload. Also, in atrial fibrillation response with a heart rate mildly tachycardic at 100-110. Will initiate intravenous Lasix 40 mg this afternoon. Lovenox (blood thinning medication) for anticoagulation while in the hospital. A Medication Error Report completed by the DON on 8/04/23 documented resident #42 had a physician order for Lasix 20 mg by mouth daily x 4 days which the resident had not been administered on 8/2/23 and 8/3/23 during the morning medication pass. The Report detailed the physician had been notified on 8/04/23 at 9:05 a.m. of the failure to administer the medication. The Report further detailed the Lasix medication had not been sent from the pharmacy. The Report Outcome further detailed Resident #42 had been a direct admit to the hospital. The Corrective Action Taken described a verbal warning and a two-day suspension during the investigation of the nurse (Staff G) involved in the incident. The Measures Taken to Prevent a Reoccurrence of a similar error detailed education and competency skills would be completed for all nursing staff. Staff G signed the Medication Error Report on 8/07/23. A Facility Reported Incident (FRI) detailed the facility submitted information to the Iowa Department of Inspection, Appeals and Licensing on 8/07/23 at 4:33 p.m. notifying the State Agency Resident #42 had a new Lasix 20 mg daily x 4 days order. The Report identified a nurse had not administered the Lasix medication on 8/2/23 and 8/3/23 which resulted in resident harm involving hospitalization. The facility became aware of the incident on 8/04/23 and a full investigation had been initiated. During an interview on 8/08/23 at 10:14 a.m. Staff G reported Resident #42 did not receive the Lasix as ordered on 8/2/23 and 8/3/23. She stated the medication never came in from the pharmacy. She did not take the Lasix medication out of the emergency medication kit. She stated the pharmacy prefers for them to call the pharmacy to get the medication during normal business hours and not to take it out of the emergency medication kit. On 8/08/23 at 12:48 p.m. Staff K, RN, recalled he had more fluid. He always talked about having a hard time breathing at night. It seemed like his swelling went from one leg to the other. It was a 2+ swelling in the left below knee to the ankle. They were wrapping the right leg up to the hip, but she noticed the swelling above the knee as well as the ankle and foot. She would have thought the swelling would be on the right lower extremity due to his right hip replacement, but the swelling was on the left lower leg. She reported if she checked the MAR and the medication was not in the medication cart, she would call the pharmacy to find out where the medication was at. The facility has an after-hours pharmacy number that they can call. They very rarely take medications out of emergency kit. The pharmacy doesn't like them to do that. The pharmacy kind of bucks them on that. On 8/08/23 at 1:07 p.m. Staff L, LPN, reported Resident #42 had swelling to both lower extremities. Therapy had seen him and they started doing leg wraps. Everything was going good, then she noticed that his left leg stated swelling up. She had recommended to day shift to start getting daily weights to see if he was retaining fluids. Pharmacy has an on-call number they are to call if a medication doesn't come in. If she can she will pull from the emergency kit if the medication doesn't arrive or take from stock. She doesn't recall getting any actual training on what they are supposed to do with the emergency kit. Medications are signed off the EMAR after they are administered to the resident. During an interview on 8/08/23 at 1:47 p.m. Staff H reported he was supposed to be getting Lasix, but when she went to give the medication that Friday morning, the medication wasn't in the medication cart. She went to the DON and informed her she didn't have the medication to give. The Physician was going to see the resident on rounds that day so the Lasix medication was held. Resident #42 had swelling in his legs. She didn't notice a huge change from the day before, but his weight had gone up. They informed the physician he did not receive the medication as it wasn't available from the pharmacy. They usually call the pharmacy if they do not have the medication. If pharmacy cannot get the medication to them, then they can get the medication out of the emergency kit. Pharmacy is usually pretty good about getting medication out to the facility or they send someone from the facility to go pick up the medication. On the weekend, she doesn't know 100% what they would do. She would call the DON or ADON (Assistant Director of Nursing) to get the medication. On 8/08/23 at 1:58 p.m. Staff G reported she never called the pharmacy regarding the diuretic medication on 8/02/23 and 8/03/23. She had not realized Resident #42's diuretic had not been delivered from the pharmacy or that she had not given the medication. She reported she was just sick about what happened to the Resident. On 08/08/23 at 1:59 p.m. the ARNP reported she received a text from the DON informing her Resident #42 had not received the Lasix medication. She would have hoped that the medication would have helped but it is hard to know. She doesn't know how he would have responded because he never got a dose of Lasix. She expected the facility to administer the diuretic medication as ordered. She can't speak to the resident's condition if it would have prevented the hospitalization because he never received the medication to know how he may have responded. On 8/08/23 a review of the Emergency (Medication) Lock Box July 2023 record revealed the lock box had tag #089355 on from 7/27/23 - 8/04/23. The facility had not taken any medication out of the emergency lock box. During an interview on 8/08/23 at 2:23 p.m. the primary physician reported the resident had been admitted to the hospital in heart failure. He reported the hospitalization could have been prevented if the facility had given the Lasix medication as ordered by the ARNP. He reported if the Resident had received the two doses of Lasix prior to his visit on Friday (8/04/23) he would not have needed hospitalization. Unfortunately, he had atrial fibrillation and by Friday it had worsened due to the heart failure and not getting the medication. On 8/08/23 at 3:07 p.m. Staff I reported the resident had been filling with fluid. He still walked, but he commented on how much his legs were swelling. He voiced he was uncomfortable and couldn't eat. They had called and the nurse practitioner who was coming in to see the resident. During an interview on 8/08/23 at 3:48 p.m. the Director of Nursing (DON) reported Staff H informed her she couldn't find a card of Lasix in the medication cart around 8:30 a.m. Prior to that no one knew the Lasix had not come from the pharmacy or been administered. The physician had routine rounds due that day and he saw Resident #42 as the last patient of the day. The physician thought it was in the best interest of the resident to be admitted as he had atrial fibrillation with his heart rate in the 100's and he needed diuresis. She reported she called the pharmacy on 8/04/23 and the pharmacy stated they didn't fill an order for Lasix as they didn't receive the faxed order. The DON stated there were other faxes sent at the same time and they received those medication orders. Normally, if a medication is not delivered, they call the pharmacy to follow-up. The ARNP came in on 8/01/23 between 1-2 p.m. so the medication was faxed in and not taken out of the lock box. She didn't feel that resident #42 was in any acute distress to need to start the medication on 8/01/23. She expects the nurses to call the pharmacy and follow-up if a medication was not delivered to the facility. The facility will send someone to get the medication. On 8/08/23 the DON submitted a Medication Reorder Form. She reported the nurses send the medication reorder form to the pharmacy. There is no set nurse that performs the duty or a set time they send the reorder form to the pharmacy. The Medication Reorder Form just goes to the pharmacy whenever it needs to go. During an interview on 8/08/23 at 4:17 p.m. the Pharmacy Technician that services the facility reported the DON had called her the morning of 8/04/23. She reviewed the pharmacy orders for resident #42 and they had not received any Lasix orders for the resident. The pharmacy never sent any Lasix to the facility as they had never received any order for the medication from the facility. She communicated there have been numerous times when the facility faxes had come into the pharmacy blank and their staff had to call out to the nursing home to check on the physician orders. This happens at least a few times a week where she has to talk to the nurse or the DON. It is a problem. They just seem to laugh about it and nothing gets done. As far as she knows they had not taken any corrective actions. Many times they send medication order faxes at night that come in blank and she has to call the facility in the morning to have them re-fax the orders. She reported they do not want the nurses opening the emergency medication kit during normal business hours. They are to call the pharmacy with any new orders and they will schedule a delivery or the facility can send someone to pick up the medication. She checked the 8/1/23, 8/2/23, and 8/3/23 nursing home deliveries. She did not receive any Lasix order for Resident #42. The nurses should fax each persons physician orders separately. If there are 5 resident orders all together the pharmacist has to dig through all the papers which can create errors. On 8/09/23 at 2:48 p.m. the Regional Director of Operations reported the DON had sent multiple resident physician orders to the pharmacy on 8/01/23 all together as one fax. There were 5 resident's orders faxed in together. She reported when the DON had checked with pharmacy the pharmacy had stated they got all the physician orders, except Resident #42's orders. They had provided education to the DON on 8/04/23 to send all resident physician orders to the pharmacy separately. On 8/09/23 at 3:18 p.m. the Pharmacy Technician reported she had reviewed the orders and delivery slips for 8/1/23, 8/2/23 and 8/3/23 again and did not find any Lasix orders that came in for Resident #42. She remembers talking to the DON on 8/04/23 the DON asking about the Lasix order for Resident #42. She said she could get the Lasix order ready and they could come pick it up. The DON reported no, they were going to have the physician see the resident that morning. She reported a blank order sheet came in on 8/3/23 from the facility with no orders on it. The pharmacy has offered to talk to their corporate as there is definitely a communication problem, but they will not give them any corporate contact numbers. A Review of the Pharmacy Medication Packing Slips completed on 8/09/23 revealed the following: a. 8/01/23 showed Resident #42 received an order for Nystatin Topical. No Lasix delivered for Resident #42. The Packing Slip provided by the facility as part of the facility investigation did not contain a nurse signature for delivery. b. 8/02/23 revealed no Lasix delivered for Resident #42. The Packing Slip provided by the facility as part of the investigation did not contain a nurse signature for the delivery. c. 8/03/23 showed no Lasix medication delivered to the facility for Resident #42. Staff H signed for the delivery on 8/03/23 at 5:10 p.m. During an interview on 8/10/23 at 8:32 a.m. the DON reported the facility did not have a process in place to reconcile medications delivered to the facility against the physician orders that were called/faxed in. It hadn't been a problem. The nurses check off what the pharmacy delivers against the pharmacy delivery slip. They really didn't keep a list of what was ordered from the pharmacy so the nurses do not have anything to compare to when the pharmacy delivers the medications. It had been a busy day that day and it was unusual for them to have that many orders faxed to the pharmacy at one time. There were no set processes in place for the nurses to check medications delivered against the orders that were sent to the pharmacy. She had been communicating to the charge nurses' physician orders called to the pharmacy since that time so they know when the medications come in from pharmacy. There have been no undelivered medications since 8/04/23. During an interview on 8/10/23 at 11:48 a.m. the Administrator reported she felt there needed to be more investigation into why the pharmacy did not receive the physician order for Resident #42's Lasix. She felt there needs to be more checks and balances, but unfortunately the pharmacy manager is off this week so they haven't been able to sit down and meet with her to develop more solutions to know if this is an electronic issue. She said last week there was a call from the pharmacy stating there was a blank page that came through and she had to check with nursing on that. She is not sure if it is one facsimile (fax) machine or both facility fax machines that could be the problem. She reported they need to put a process into place to reconcile the medication orders placed to the pharmacy with the orders that are received from pharmacy. She placed a binder last evening 8/09/23 for the nurses to pull all orders called/faxed to pharmacy in. The nursing fax machine was set up on 8/0923 by the Regional Director of Operations to provide a fax confirmation slip which the nurses will also put with the order in the binder. She is not sure why the nursing fax machine had never been set up to provide a confirmation fax notice. The nurses are to confirm the medication delivery slip and the medications delivered with the physician orders in the binder. She is continuing to provide additional education to the nurses and follow-up on this practice. She reported they provided policy training to all nurses on their pharmacy services policy on 8/08/23. On 8/10/23 at 1:28 p.m. the DON reported the facility uses the pharmacy provided policies. The Pharmacy Ordering and Receiving Medication from the Dispensing Pharmacy Policy, provided by the facility stated medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medications order and receipt. The Policy Procedure for Receiving Medications from the Pharmacy directed the following: 1. A licensed nurse: a. Receives medications delivered to the facility and documents that the delivery was received and was secure. b. Verifies medications received and directions for use with the medication order form. c. Promptly reports discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor. d. Immediately delivers the medications to the appropriate secure storage area or a designee under the direct supervision of a licensed nurse. e. Assures medications are incorporated into the resident's specific allocation prior to the next medication pass. f. Signs two copies of the delivery record - one is returned to the pharmacy and one is retained at the facility.