**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility incident reports, and facility staff interview, the facility failed to administer two doses of insulin for 1 of 3 residents (Resident #1), and remove a transdermal pain patch prior to application of a new patch and notify physician and responsible party of the error for 1 of 3 residents (Resident #2) reviewed for medication administration. The facility reported a census of 51 residents. Findings include: 1. A review of [name redacted] hospital discharge orders, dated 3/6/24, Medication List revealed the following orders, in part: a. Insulin glargine 100 unit/ml (milliliters) (3 ml) injection pen. Dosage: Inject 18 units subcutaneously daily. Last time this was given: 18 units on March 5, 2024 8:50 PM. Diagnosis: Type 2 diabetes mellitus without complication, without long-term current use of insulin. b. CONTOUR NEXT EZ METER Dosage: USE TO CHECK BLOOD SUGAR THREE TIMES A DAY c. SUPPLY CONTOUR NEXT test strips Dosage: Use 1 strip three times a day to test blood sugars. d. SUPPLY lancets Dosage: Use to test blood sugar 4 times daily. Diagnosis: Type 2 diabetes mellitus without complication, without long-term current use of insulin. A review of a N ADV-Clinical admission document revealed Resident #1 admitted to the facility on [DATE]. The Mental Status section of the document indicated Resident #1 verbal, confused, oriented to person, and a mild cognitive impairment. The assessment did not include information about the need for blood sugar checks. The Baseline Care Plan, Section 3. Health Conditions, dated 3/06/24, indicated Resident #1 diabetic. The D. Medications section did not indicate resident taking insulin. The Care Plan, Date Initiated 3/21/24 and 3/25/24, did not include a Focus area to address a diagnosis of diabetes mellitus, and the use of insulin. A review of the March 2024 Medication Administration Record (MAR), revealed an order for Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Glargine) Inject 18 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high blood sugar) Start Date 3/7/24 with D/C (discontinue) Date 3/10/24. A review of the MAR indicated the medication administered in the AM on 3/7/24, 3/8/24, and 3/9/24. A review of the March 2024 MAR revealed an order for Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Glargine) Inject 18 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA , State Date 3/10/24, D/C Date 4/1/24. A review of the MAR indicated the medication administered HS (bedtime) on 3/10/24 through 3/31/24. A review of the March 2024 MAR revealed an order for HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject 6 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Start Date 3/10/24, D/C Date 4/1/24. A review of the MAR indicated Insulin Lispro not administered to the resident three times daily on 3/15/24. The AM and NOON dose coded with a number 9'. The Chart Codes listed on the MAR indicated a 9 is used to communicate Other/See Progress Notes. A review of the March 2024 MAR revealed an order for Blood sugar checks TID (three times) three times a day related TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED Start Date 3/6/24, D/C Date 5/10/24 revealed a number 9 coded for both morning and noon blood sugar checks on 3/15/24. A clinical record review revealed the following notes related to the code number 9: a. On 3/15/24 at 3:57 PM, a X-Orders-Administration Note Note Text: Blood sugars checks TID three times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED forgot b. On 3/15/24 at 3:58 PM, a X-Orders-Administration Note Note Text: HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML Inject 6 unit subcutaneously with meals related to TYPE @ DIABETES MELLITUS WITHOUT COMPLICATIONS forgot c. On 3/15/24 at 3:59 PM, a X-Orders-Administration Note Note Text: Blood sugars checks TID three times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED forgot d. On 3/15/24 at 3:59 PM, a X-Orders-Administration Note Note Text: HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML Inject 6 unit subcutaneously with meals related to TYPE @ DIABETES MELLITUS WITHOUT COMPLICATIONS forgot A Nurses Note, dated 3/15/24 at 7:15 PM documented Dexcom (a device for continuous blood sugar monitoring) alarming for high glucose. Monitor reads 268. Fingerstick done shows 300. Monitor calibrated. no s/s (signs/symptoms) hyperglycemia. Scheduled insulin given. Will check again prior to bedtime. An incident report documenting missed insulin doses and blood sugar checks not present in Resident #1 clinical record. During an interview on 10/24/24 at 1:30 PM, Staff A, Registered Nurse (RN), stated nurses are instructed to alert the Director of Nursing (DON), notify the resident's Primary Care Provider for any additional instructions and notify the resident's responsible party for any omitted medications and then complete an incident report for the occurrence. During an interview 10/24/24 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN), stated if a resident's medication had not been administered, the nurse should notify the doctor and let the family know. On 10/25/24 at 2:33 PM, an email received from the Administrator confirmed Resident #1 morning and noon doses of HumaLOG had been omitted and the facility lacked an incident report on the occurrence. During an interview on 10/28/24 at 10:10 AM, Director of Nursing (DON), stated she would expect nurses to complete a risk management (incident report) for any medication errors and notify the Primary Care Provider right away with medication errors. 2. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 for Resident #2, which indicated moderate cognitive impairment. Diagnoses included cancer, arthritis, fractures of left side ribs, and non-Alzheimer's dementia. The MDS indicated Resident #2 required opioid (pain) medication. The Care Plan, revised 8/14/24, revealed Resident #2 utilized pain medication. The Care Plan instructed staff to provide medications as ordered and to monitor/document side effects and effectiveness. A review of the August 2024 MAR revealed an order for Fentanyl 12MCG/HR (micrograms per hour) APPLY ONE PATCH TOPICALLY TO SKIN EVERY 3 DAYS REMOVE OLD PATCH PRIOR TO NEW PATCH, ROTATE SITES (Related Diagnoses: Other chronic pain) Start Date 8/9/24. The MAR revealed Resident #2's Fentanyl patch was changed on 8/30/24 with a new patch applied to the upper back. A review of the September MAR revealed Staff A, Registered Nurse (RN) changed Resident #2's Fentanyl patch on 9/02/24, with a new patch applied to the upper back. The facility provided a document, dated 9/5/24, titled Medication Error. Incident Description Section, Nursing Description: Resident [Resident #2] found 2 fentanyl patches on. One dated 8/30 & one dated 9/2. Patch on 9/2 applied by [name redacted] RN (Registered Nurse). Immediate Action Taken Section, Description: Both patches removed as new one due today. Statement Section: No Statements Found. Agencies/People Notified: [name redacted] Director of Nursing. Notes Section: 9/5/24 Education to staff to check for placement of all patches and remove before applying new patch. DON initialed. A review of Nurses Notes revealed no entry regarding notification of physician and responsible party regarding the medication error. During an interview on 10/24/24 at 1:30 PM, Staff A, RN stated the process for changing a Fentanyl patch included a check of the resident to ensure the old patch is found and removed before a new patch is applied. Staff A stated she had changed Resident #2's Fentanyl patch on 9/02/24 and recalled being unable to find the old patch on the resident. Staff A revealed that the nurse would complete an incident report when any medication error had been found, which included notification to physician and responsible party. During an interview on 10/28/24 at 10:10 AM, Director of Nursing (DON), stated the expectation of nurses to complete an incident report for any medication error and for timely notification to the provider of incident. DON informed that staff had watched Resident #2 following incident for any side effects and confirmed that Electronic Health Record (EHR) had lacked this documentation.

Based on observation, clinical record review, policy review, and staff interview, staff combined medications without an order to do so during the administration of g-tube (gastrostomy tube-a tube inserted through the abdomen which brought nutrition and medications directly to the stomach) medications for 1 of 1 residents reviewed with a g-tube(Resident #10). The facility reported a census of 50 residents. Findings: The Minimum Data Set (MDS) assessment tool, dated 1/19/24, listed diagnoses for Resident #10 which included non-Alzheimer's dementia, Parkinson's disease (progressive disorder that affected the nervous system and the parts of the body controlled by the nerves), and depression. The MDS stated the resident had a feeding tube and listed the resident's Brief Interview for Mental Status (BIMS) score as 1 out of 15, indicating severely impaired cognition. The facility policy Medication Administration Through Tube Feeding, last revised 7/2016, directed staff to administer each medication separately. A 3/30/22 Care Plan entry stated the resident had a g-tube for supplemental feedings. A 3/5/23 Care Plan entry directed staff to provide medications per the order. The April 2024 Medication Administration Record (MAR) listed a 2/19/24 order for carbidopa/levodopa(a medication used to treat Parkinson's) 25-100 milligrams(mg) 1.5 tablets three times daily and a 2/20/24 order for quetiapine (an antipsychotic) 50 mg three times daily. The MAR lacked an order to combine the medications during g-tube medication administration. During an observation on 4/2/24 at 11:00 a.m., Staff A Licensed Practical Nurse(LPN) crushed the following medications and mixed them with water: 1. carbidopa/levodopa 25-100 mg 1.5 tablets 2. quetiapine 50 mg tablet Staff A then instilled a water flush, instilled the medications mixed with the water, and instilled a water flush. On 4/2/24 at 1:08 p.m., Staff A stated there should be an order to combine medications during g-tube medication administration and stated she would check. On 4/2/24 at 2:05 p.m., Staff A stated she obtained an order to combine the medications.

Based on observations, policy review, and resident, and staff interviews, the facility failed to timely assist residents who needed assistance for 3 of 16 residents reviewed (Resident #12, #42, #40). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #12 dated 2/7/23 documented a Brief Interview Mental Status (BIMS) score of 03, which indicated severely impaired cognition. The MDS identified that Resident #12 needed extensive assistance with bed mobility, walking, transfers, dressing, toilet use, and personal hygiene. The MDS listed the following diagnoses of Non Alzheimer's Dementia and Parkinson's disease. The Care Plan Focus dated 1/6/23 identified goals for communication, nutrition, fall prevention, UTI prevention and continence; The Care Plan interventions dated 1/6/23 included: 1. Ensure the resident has an unobstructed path to the bathroom. 2. Assist to the toilet 4 x per shift and prn. 3.The resident would like to have time to consume meals, not be rushed. 4. Anticipate and meet The resident's needs On 2/20/23 at 3:31 PM a family member of Resident #12 stated she believed staffing problems resulted in multiple falls and an injury for Resident #12. Family member of Resident #12 said there were enough staff on the weekends and the facility needed more help. On 2/21/23 at 7:26 AM revealed Resident #12 at the breakfast table in his wheelchair waiting for food. Resident #12 raised his hand for assistance but staff did not see him. Resident #12 pushed himself in his chair toward Staff A, [NAME] and tried several times to get her attention. On 2/21/23 at 7:29 AM Resident #12 was noticed by Staff A. Resident #12 stated he needed to use the bathroom. Staff A, said she would get someone else to help Resident #12. On 2/21/23 at 7:34 AM Resident #12 waited in the wheelchair. He moved himself close to the kitchen where Staff A stood. On 2/21/23 at 7:43 AM Resident #12 raised his hand again for assistance. Staff A was present but did not note the wave. On 2/21/23 at 7:44 AM Resident #12 raised his hand again and shook it in the air for a few seconds. No staff noted Resident #12. On 2/21/23 at 7:45 AM Staff A asked Staff B Licensed Practical Nurse (LPN) for assistance with changing paper towels. Staff A did not mention Resident #12 or his need to use the restroom. On 2/21/23 at 7:47 AM Staff A stated Resident #12, you still haven't gotten there? I'm sure they are coming, they must be busy with someone else. On 2/21/23 at 7:52 AM Resident #12 was greeted by Staff E, Housekeeper. Resident #12 told Staff E he needed to use the restroom. Staff E consulted with Staff A who advised that Resident #12 needed to wait for assistance. Staff E pushed Resident #12 from the dining room to the hallway facing his room. On 2/21/23 at 7:57 AM Staff C, Certified Medication Aide (CMA) took Resident #12 to the bathroom. On 2/21/23 at 8:20 AM Resident #12 returned to the dining room. On 2/21/23 silverware was brought to the table for Resident #12 On 2/21/23 at 9:01 AM juice and water were provided to Resident #12. On 2/21/23 at 9:53 AM food was delivered to Resident #12 who used an adaptive plate and utensil to feed himself. 2. The Minimum Data Set (MDS) for Resident #42 dated 12/29/22 documented a Brief Interview Mental Status (BIMS) score of 04, which indicated severely impaired cognition. The MDS identified that Resident #42 needed extensive assistance with bed mobility, walking, transfers, dressing, toilet use, eating and personal hygiene. The MDS listed the following diagnoses of Alzheimer's Disease and Parkinson's disease. The Care Plan Focus dated 1/6/23 identified goals for communication and nutrition. The Care Plan interventions dated 1/6/23 included: 1. Encourage adequate nutrition and hydration. 2. The resident would like assist of one with eating 3. Anticipate and meet needs. On 2/21/23 at 7:27 AM Resident #42 spilled a drink at the dining room table. The plastic glass made a loud noise heard by two DIA staff in the area. There was no response from staff A, Cook or Staff C CMA who were also in the room. A puddle of liquid formed to the left of Resident #42's wheelchair. On 2/21/23 at 7:48 AM Staff E, Housekeeper noted the spill and alerted Staff B, LPN who assessed Resident #42 for wet clothing. On 2/22/23 01:29 PM the Administrator stated that the expectation for staff response to residents is 12 to 15 minutes or less. The administrator stated that she expected food to be delivered as soon as possible to residents. The Administrator agreed that being in the dining room at 8:30AM and getting food at 10:00 AM would be too long to wait. A call light policy for the facility stated a purpose of the call light is to respond promptly to resident's call for assistance. 3. Significant Change MDS for Resident#40 dated 1/30/23 documented diagnoses which included, heart and lung disease included chronic obstructive pulmonary disease (COPD), Spinal stenosis, arthritis, osteoporosis, weakness. The MDS documented that the resident needed assistance with personal cares, and extensive assistance of one for transfers, walking, dressing and toilet use. Resident #40 BIMS score coded 15 which indicated cognitively intact. Care plan dated 11/4/22 for Resident #40 documented focus area, activities of daily living self-care performance deficit related to activity intolerance. Interventions included ambulation to assist of one using a gait belt and walker, for toileting, assisted of one with toileting. Interview on 2/21/2023 at 10:23AM Res.#40 reported up to 45 minutes for staff response to the call button, and reported to watch the clock. The resident also stated sometimes my bladder can't wait. On 2/21/2023 the Assistant Director of Nursing (ADON) reported the expectation is call lights should be answered 10-15 minutes. A call light report was requested, policy was provided. Review of call light report provided by the Director of Nursing (DON) for 2/20/23 revealed for Resident #40: a. On 2/20/23 at 7:19 AM response was 21 minutes. b. On 2/20/23 at 1:02 PM response was 19 minutes. c. On 2/20/23 at 2:10 PM response was 24 minutes.