**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to follow Physician's orders for self-administration of medications for one (1) of six (6) sampled residents observed for medication administration, Resident #2. The findings include: Review of the facility's policy titled, Administration of Medication dated 02/01/2007, revealed its purpose as preparing and administering all medication to residents, accurately and effectively according to Physician's orders. Further review of the policy revealed staff administering medications were to never leave medication in a resident's room, unless an order to do so is on the chart. Review of Resident #2's medical record revealed the facility admitted Resident #2 on 10/23/2018, with diagnoses which included Hypertension (high blood pressure), Acute Pain due to Trauma, Anemia, and Chronic Fatigue. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated he/she was cognitively intact. Review of Resident #2's Physician's Order Sheet and Progress Notes, dated 06/08/2022, revealed Resident #2's was noted to have an inability to make decisions on his/her own. Continued review revealed a recommendation for nursing staff to administer Resident #2's medications due to the resident's confusion with his/her medications. Review of Resident #2's Nurse's Note, dated 06/08/2022, revealed a new order to discontinue the resident's ability for self-administration of medications. Continued review revealed staff talked with Resident #2's power of attorney (POA) about the resident's inability for decision making. Observation and interview on 08/09/2022 at 10:00 AM, revealed Resident #2 sitting up in a recliner, finishing his/her breakfast, with two (2) white pills in a medication cup on the bedside table. Continued observation revealed Resident #2 was alone in his/her room. Interview with Resident #2 revealed he/she wanted to finish breakfast, and then would take the two (2) pills in the medication cup. Further interview revealed Resident #2 stated he/she thought the two (2) pills were vitamins. Review of Resident #2's August 2022 Medication Administration Record (MAR) revealed medications ordered at 9:00 AM included: Cymbalta 20 milligrams (mg) one (1) tablet every day (QD) started on 10/23/2018 (an anti-depressant); Benicar 40 mg QD started on 10/23/2018 (for high blood pressure); Osteobiflex one (1) tablet QD started on 10/23/2018 (a supplement); Imdur 30 mg half a tablet started on 09/11/2019 (an anti-anginal); Vitamin D 2,000 units QD started on 01/08/2020 (a supplement); Cranberry Extra CP 250 mg two (2) tablets QD started on 01/04/2022 (a supplement); Prilosec 20 mg QD started on 04/13/2022 (gastric acid reducer); Tylenol Arthritis Extended Release (ER) one (1) tablet three (3) times per day (TID) started on 09/30/2021 (pain reliever); Ditropan 5 mg tablet two (2) times per day (BID) started on 04/15/2020 (smooth muscle relaxant); Colace 100 mg BID started on 04/13/2022 (laxative); Ferrous Sulfate 325 mg BID started on 04/13/2022 (supplement); Norvasc 10 mg tablet QD started on 10/14/19 (for high blood pressure); and Coreg 12.5 mg BID started on 12/11/2019 (for high blood pressure). Continued review revealed Licensed Practical Nurse (LPN) #1 signed off as administering Resident #2's 9:00 AM medications on 08/09/2022. Interview on 08/10/2022 at 9:55 AM with LPN #1 revealed Resident #2 self-administered his/her medications previously; however, recently lost the ability to self-administer due to not taking his/her medications in a timely manner. LPN #1 further stated Resident #2 was still capable of self-administering medications, but sometimes waited too long to take the medications. Per the interview, LPN #1 stated there was no good reason she left the medications in Resident #2's room on 08/09/2022. Interview on 08/10/2022 at 3:10 PM, with the Director of Nursing (DON) revealed Resident #2 started self-administering his/her medications in April 2022. The DON further stated however, the Physician discontinued the order for Resident #2 to self-administer medications in June 2022 because Resident #2 had no longer been safe to self-administer his/her medications. A follow-up interview on 08/11/2022 at 9:00 AM, with LPN #1 revealed Resident #2 was no longer able to self-administer his/her medications, and medications should not be left in the resident's room. LPN #1 stated there was no reason for why she left the medications in Resident #2's room on 08/09/2022. LPN #1 stated staff administering medications should stand and observe a resident take their medications, but Resident #2 did not like staff standing there during medication administration. Interview on 08/11/2022 at 9:23 AM, with Resident #2's Physician revealed she discontinued Resident #2's order for self-administration in June 2022. According to the Physician, on 06/08/2022, she was rounding with the DON and found three (3) medication cups with pills in them in Resident #2's room. The Physician stated she was concerned that Resident #2 did not take all his/her medications when self-administering them, and so had discontinued the self-administration order for safety reasons. The Physician further stated nursing staff should administer all of Resident #2's medications as per the order. A follow-up interview on 08/11/2022 at 9:45 AM, with the DON revealed staff should not leave residents' medications in their rooms unless the resident had a current order for self-administration. The DON stated Resident #2's self-administration medication order was discontinued in June 2022 for safety reasons, and it was clear the resident had not been taking all his/her medications as ordered. Further interview revealed there was no known outcome from Resident #2 not taking his/her medications in a timely manner; however, it was important for nursing staff to ensure all medications were administered as ordered. Interview on 08/11/2022 at 10:03 AM, with the Administrator revealed she expected nursing staff to not leave medications in a resident's room. The Administrator stated when the Physician found the pills in Resident #2's room, she discontinued the resident's self-administration order. Further interview revealed it was important for nursing staff to ensure residents took their medications as ordered for the residents' safety.

Based on observation, interview, record review, and review of facility policy, it was determined that the facility failed to ensure the medication error rate was less than five (5) percent. Observation of medication administration on 05/16/19 revealed thirty-two (32) medication opportunities were observed with two (2) errors, resulting in a medication error rate of 6.25 percent. The findings include: Review of the facility policy, Administration of Medication, dated 02/01/17, revealed residents would be administered medications accurately and effectively according to physician's orders. Review of Resident #41's physician orders dated April 2019 revealed staff were to obtain the resident's blood pressure and pulse prior to administration of the medications Carvedilol and Norvasc (medications utilized to treat hypertension). Further review of the physician orders revealed if the resident's blood pressure and pulse were outside of parameters established by the physician, the medication was to be held and not administered to the resident. However, observation during the medication administration for Resident #41 on 05/15/19 at 8:45 AM, revealed the Medication Aide failed to obtain the resident's blood pressure and pulse until the medications Carvedilol and Norvasc had already been administered to the resident. Interview with the KMA on 05/16/19 at 9:23 AM, revealed she had mistakenly administered Resident #41 the medication prior to obtaining the resident's blood pressure and pulse as ordered. She further stated the blood pressure and pulse should have been obtained prior to administering the Carvedilol and Norvasc to determine if the medication should be held. Interview with the Assistant Director of Nursing on 05/16/19 at 11:40 AM, revealed she conducted competency evaluations for staff administering medications annually and stated there had been no concerns related to the KMA's previous competency evaluations. Interview with the Director of Nursing on 05/16/19 at 11:37 AM, revealed it was the expectation of the facility that staff administering medications would read the physician's order prior to administering medication and follow those orders.