**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, records, and policies reviewed, the facility failed to ensure that one Resident (#95) out of a total sample of 34 residents, maintained acceptable parameters of nutritional status. Specifically, the facility failed to ensure Resident #95's weight was monitored when a weight change occurred, per facility policy, and resulted in significant weight loss and failed to notify the physician after significant weight loss was identified after Resident #95's gastrostomy tube (a tube inserted into the stomach to provide nutrition) was accidentally removed and not replaced. Findings include: Review of facility policy titled 'Weight Assessment and Intervention' dated March 2023, indicated the following but was not limited to: -Resident weights are monitored for undesirable or unintended weight loss or gain. -The Dietician will respond timely to a verified significant weight change. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant. b. 6 months - 10% weight loss is significant. -The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia weight loss or increasing the risk of weight loss for example a. Fluid and nutrient loss b. Inadequate availability of food or fluids c. Increased need for calories and or protein -care planning for weight loss our impaired nutrition is a multidisciplinary effort and includes the physician nursing staff, the dietitian the consultant pharmacist and the resident legal surrogate. -individualized care plans are addressed to the extent possible they identified causes of weight loss goals and benchmark for improvement and time frames and parameters for monitoring and reassessment. -interventions for undesirable weight loss shall be based on careful consideration of the following a. Nutrition and hydration needs of the residents. b. The use of supplementation and all feeding tubes Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia and dependent on tube feeding, gastrostomy status, unspecified severe protein calorie malnutrition. Review of Resident #95's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was conducted which indicated the Resident had a memory problem and was cognitively impaired. The MDS further indicated that the Resident was dependent on tube feeding. On 4/30/24 at 9:08 A.M., the surveyor observed Resident #95 lying in bed, he/she was observed to be very thin in appearance. The Resident was not able to be interviewed. Review of nursing progress note dated 3/8/24 indicated the following but not limited to: Patient removed gastrostomy- tube (g-tube ) intact, attempts to replace g-tube with foley catheter failed secondary to gastrostomy site no longer patent (accessible) medical director made aware. Order obtained to schedule patient for interventional radiology (IR) for g-tube replacement, return call pending at this time, patient on modified diet and has adequate by mouth intake to cover through weekend, encourage fluids, guardian aware, dietician and speech language pathologist following. Review of dietician progress note dated 3/8/24 indicated the following but not limited to: -Resident weight stable times one week. G-tube dislodged the morning, medical director aware, plan for g-tube replacement 3/11/24. Will optimize by mouth intake with Med pass 2.0 (a nutritional supplement) four ounces three times a day between meals. 12 ounces daily will provide 720 kilo calories and 30 grams protein. Phone the guardian without answering. Registered dietician to closely monitor. Review of the medical record indicated Resident #95 weighed 125 lbs. (pounds) on 3/7/24 at the time his/her G-tube had become dislodged. Review of Resident #95's medical record indicated the Resident weighed 119.4 lbs. (a weight loss of 4.48%) on 3/11/24, in only three days after the g-tube became dislodged. Review of Resident #95's physician notes failed to indicate that the physician was notified of the weight change from 3/7/24 to 3/11/24. Review of Resident #95's nutritional orders failed to indicate a new intervention was added to address the immediate weight loss on 3/11/24. Review of Resident #95's medical record indicated the Resident had an appointment for the G-tube to be replaced on 3/15/24. Review of nursing progress note dated 3/15/24 indicated the following but not limited to: -Patient returned from interventional radiology no g-tube placed, tract scarred and unable to be accessed, medical director (MD) aware and will follow up with MD at IR regarding appropriate plan. Review of Resident #95's weekly weights after the G-tube had failed to be replaced indicated the following: -3/20/24 109 lbs. (a significant weight loss of 12.80% since the G-tube had been dislodged.) -3/22/24 110.6 lbs. (a confirmation of the significant weight loss) -3/11/24 119.4 lbs -3/7/24 125 lbs Resident #95's medical record failed to indicate the physician was notified immediately after the continued weight loss which had become significant as of 3/20/24. In addition, the medical record failed to indicate any new nutritional interventions were put into place after the significant weight loss. Review of a dietician progress note dated 3/22/24 indicated the following: re weigh requested due to significant variation compared to previous weights slash weight trends noted GTube unable to be replaced by interventional radiology weight 109 lbs. Review of dietician progress note dated 3/23/24 indicated the following rere-weigh (sic) indicates accurate significant weight loss encouragement of by mouth fluids and food provided while patient alert and able to safely take by mouth. Appreciate nursing diligence. By mouth intake remains inadequate with subsequent weight loss pending referral for G tube replacement plan to continue to optimize current nutrition intervention ONS (oral nutritional supplements) 4 times a day fortified foods at meals and snacks slash fluids between meals wait 110.6 pounds. Review of the RD progress note dated 3/23/24 indicated the following: Reweight indicates accurate, significant weight loss, current BMI (Body Mass Index) of 15 kg/m2 indicates underweight status. Medical director and nursing aware. Nursing attempt for IV access for hydration, unable to place IV for fluids. Review of nursing note dated 3/25/24 indicated the following: MD into asses, poor by mouth intake, patient refusing to allow IV access, subcutaneous access established to left upper extremity, normal saline running at 60 milliliters per hour. On 3/26/24 the following nursing note indicated: Patient with increased lethargy, unable to swallow and by mouth, no g-tube access. Resident was transferred to the hospital. Review of history and physical report dated 3/26/24 from the hospital indicated the following: -Resident's g-tube was accidentally dislodged on 3/8/24, patient was sent to IR on 3/15/24 for replacement however tract was not salvageable. Patient was sent back to facility without enteral access or acceptable nutrition plan and no planned procedure date for G tube replacement patient only able to tolerate small amounts of by mouth intake since 3/8/24 resulting in 15 lbs. (pounds) weight loss as patient has been without necessary tube feeding to maintain weight for 20 days. Patient was found to have lost about 15 lbs. and appeared dry hence the referral to the emergency department. Review of the Adult Malnutrition Assessment form completed when the Resident was inpatient in the hospital, dated 3/29/24 indicated the following: -this patient has been identified as meeting criteria for malnutrition based on etiology-based definitions BMI calculated 16.2. Adult malnutrition code as identified by dietician severe. During an interview on 5/2/24 at 10:24 A.M., Certified Nursing Assistant (CNA) #1 said the Resident loves to eat and would eat most meals fully when awake. CNA #1 said Resident #1 was provided with cereal at breakfast and only potatoes at lunch throughout the time the G-tube was dislodged. She further said she offers him/her snacks if the Resident wants. CNA #1 said she does not remember offering the Resident snacks when the tube feeding was dislodged. On 5/2/24 at 12:36 P.M., the surveyor asked the Food Service Director to print out Resident #95's meal ticket. Review of the diet slip provided by the food service director for Resident #95 indicated the following: -Breakfast pureed small portion: Mildly thick cranberry juice and puree hot cereal only. -Lunch Pureed small portion: Mildly thick cranberry juice super mashed only for lunch no dessert. -Dinner pureed small portion: Mildly thick cranberry juice puree protein only for supper no dessert. The Food Service Director said the meal ticket had been the same with the same portions with no changes since the previous month. During an interview on 5/2/24 at 10:26 A.M., Unit Manager #1 said all the residents on the short-term unit are on weekly weights unless otherwise ordered. She said the Unit Manager and the Registered Dietician are responsible for looking at the weights and recognizing weight changes. If weight loss notification is done to RD, MD, and resident representatives. Furthermore, interventions are made immediately. The UM said that she believed the Resident weights had been stable as the Resident was eating by mouth when the feeding tube had dislodged. The UM confirmed that a weight loss had occurred on 3/11/24 and no new intervention had been added. The UM said the Resident feeding tube was not replaced until 3/26/24 and at that time the Resident had lost significant weight. The UM said the Medical Director had not seen the Resident as the Resident did not have a skilled need. During an interview on 5/2/24 at 9:14 A.M., the Registered Dietician (RD) said the Resident was dependent on tube feeding for his/her daily caloric intake. She said the Resident ate pleasure foods by mouth only when arousable. She said the physician was aware that the Resident was dependent on tube feeding when the tube feed had dislodged. The RD said the intake of pleasure feeding was between 25-75% of meals and snacks offered. The RD said she did not check on the Resident's daily food consumption when the tube feeding was dislodged. The RD said she had added med pass 2.0 on 3/8/24 which was the only new intervention added throughout the period of weight loss. The RD said the physician was aware the tube feed needed to be replaced but was not aware of the initial weight loss on 3//11/24. The RD said she wrote an email to the MD on 3/22/24 inquiring about the status of the g-tube replacement as the Resident had lost 10 lbs. since the tube dislodged. The surveyor reviewed the correspondence to the MD from the RD dated 3/22/24. During an interview on 5/2/24 at 9:44 A.m., the Medical Director said he was relying on nursing staff to communicate with him regarding Resident #95's care. The MD said the nursing staff had made him aware that the Resident's intake had been adequate since the g-tube had dislodged on 3/8/24, but said he was unaware the Resident was still only eating a pleasure food portion, not a full meal. He further said there was a delay in his part, and he should have sent the Resident to the hospital sooner had he been aware that the Resident was having a rapid decline in weight loss. The MD said when he saw the Resident on 3/25/24 the Resident was dehydrated, his/her ability to swallow had declined and IV fluids had been started two days before the Resident was transferred to the hospital. The MD said the Resident should have been monitored closely due to being at high risk for dehydration and the fact that the Resident who depended on tube feeding for his daily intake needs was not getting the same amount of intake. The MD said that he never received an email communication from the RD on 3/22/24 regarding concerns with Resident #95. During an interview on 5/2/24 at 12:39 P.M., the Director of Nursing said the risk team did not follow the Resident as he/she resided in the short-term unit. She further said the RD should have monitored the Resident closely, as the RD would be the one to make recommendations to the MD. Refer to F693

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy and record reviews, the facility failed to ensure that one Resident (#95) of one applicable resident, in a total sample of three residents, who received enteral nutrition (method of delivering nutrition through the stomach or the small intestine) via a gastrostomy tube (G-tube: tube inserted through the abdomen into the stomach to provide nutrition) received care and services to prevent complications. Specifically, the facility failed to ensure that fluids were administered and monitored to maintain acceptable parameters of hydration, after the tube was dislodged on 3/8/24 resulting in clinical signs of dehydration and need for the administration of intravenous fluids (IV fluids: specifically formulated liquids that are injected into a vein to prevent or treat dehydration) for the Resident. Resulting in a rehospitalization on 3/26/24, 18 days after the tube was dislodged. Findings Include: Review of the facility policy titled 'Enteral Nutrition Feedings' dated revised July 2023, indicated the following but not limited to: -It is the policy of this center to provide enteral nutrition therapy to residents unable to obtain nourishment orally when such therapy is ordered by the physician and not clinically contraindicated. -Flush tube with an additional 30-60 (ml) milliliters of water or administer prescribed flushing volume prior to initiating tube feeding. Always flush with water that is approximately room temperature to avoid abdominal cramping. Review of the facility policy titled 'Resident Hydration and Prevention of Dehydration' revised October 2017, indicated the following but not limited to: -This facility will strive to provide adequate hydration and to prevent and treat dehydration. -The dietician will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. -Nurses will assess for signs and symptoms of dehydration during daily care. -If potential inadequate intake/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into a care plan. -Activities of Daily Living (ADL) status, diagnosis, individual preference, habits, and cognitive and medical status will be considered in all interventions. -The physician will be notified. -The dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. -Laboratory tests may be ordered to assess hydration; the physician may initiate IV hydration. Hospitalization will be recommended as necessary. Review of the Merck Manual article, Hypernatremia ([NAME], [DATE]) at https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/hypernatremia indicated the following: -In hypernatremia, the level of sodium in blood is too high -Hypernatremia involves dehydration, which can have many causes, including not drinking enough fluids . -Blood tests are done to measure the sodium level -Usually, fluids are given intravenously to slowly reduce the sodium level in the blood. Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia and dependent on tube feeding. Review of Resident #95's Minimum Data Set (MDS) dated [DATE] indicated a Staff Assessment for Mental Status was conducted which indicated the Resident had short term and long-term memory problem and was severely impaired and never/rarely made any decisions. The MDS further indicated that the Resident was dependent on tube feeding. Review of Resident #95's diet care plan date revised 10/4/21 indicated the following interventions: -Enteral nutrition per physician's orders -Solids puree solids -Liquid consistency: Mildly Thick Nutrition noted dated 2/29/24 indicated the Resident was receiving the following: -Jevity 1.5 at 60 milliliter/ hour times 24 hours with goal of infusion of 20 hours to provide 1200 ml formula, 1800 kcals, 76-gram protein and 916 ml water. Active physician orders indicated if patient removes g-tube, replace immediately with foley catheter to maintain patency, notify MD. Review of the medical record failed to indicate the Resident was being monitored for intake or output when the tube feed had dislodged. Review of nursing progress note dated 3/8/24 indicated the following but not limited to: Patient removed gastrostomy- tube (g-tube) intact, attempts to replace g-tube with foley catheter failed secondary to gastrostomy site no longer patent (accessible) medical director made aware. Order obtained to schedule patient for interventional radiology (IR) for g-tube replacement, return call pending at this time, patient on modified diet and has adequate by mouth intake to cover through weekend, encourage fluids, guardian aware, dietician and speech language pathologist following. Review of dietician progress note dated 3/8/24 indicated the following but not limited to: -Resident weight stable times one week. G-tube dislodged the morning, medical director aware, plan for g-tube replacement 3/11/24. Will optimize by mouth intake with Med pass 2.0 (nutritional supplement) four ounces three times a day between meals. 12 ounces daily will provide 720 kilo calories and 30 grams protein. Phone the guardian without answering. Registered dietician to closely monitor. Review of nursing progress note dated 3/15/24 seven days after feeding tube had dislodged indicated the following but not limited to: -Patient returned from interventional radiology no g-tube placed, tract scarred and unable to be accessed, medical director (MD) aware and will follow up with MD at IR regarding appropriate plan. The medical record failed to indicate a plan was in place to maintain Resident #95 ' s intake and hydration as he/she was totally dependent on tube feeding for daily caloric intake. Review of the RD progress note dated 3/23/24 18 days after the tube had dislodged, indicated the following: Reweight indicates accurate, significant weight loss on 3/8/24 125.0 lbs and on 3/23/24 110.6 lbs current BMI (Body Mass Index) of 15 kg/m2 indicates underweight - 10% change. Medical director and nursing aware. Nursing attempt for IV access for hydration, unable to place IV for fluids. Review of nursing note dated 3/25/24 indicated the following: MD into asses, poor by mouth intake, patient refusing to allow IV access, subcutaneous access established to left upper extremity, normal saline running at 60 milliliters per hour. On 3/26/24, 18 days after the tube was dislodged the following nursing note indicated: Patient with increased lethargy, unable to swallow and by mouth, no g-tube access. Resident was transferred to the hospital. Review of Resident #95 ' s weights indicated the following: -3/22/24 110.6 lbs -3/20/24 109 lbs -3/11/24 119.4 lbs -3/7/24 125 lbs Review of the clinical record included the following lab work obtained on the following dates: -2/26/24 Sodium 141 (normal range) measures sodium in blood. -2/26/24 Creatinine 0.67 (normal range 0.55-1.30) measures efficiency of kidneys -2/26/24 BUN 21 (Blood urea nitrogen) (normal range 6-24) measures how well your kidneys are functioning. -3/25/24 Sodium 160 (high) (normal range 135-146) measures sodium in blood. -3/25/24 BUN 66 (high) (normal range 6-24) measures how well your kidneys are functioning. -3/25/24 Creatinine 1.60 (high) (normal range 0.55-1.30) measures efficiency of kidneys Review of the history and physical report, dated 3/26/24 from the hospital indicated Resident #95 was diagnosed with dehydration upon admission to the hospital and indicated the following: -Resident's g-tube was accidentally dislodged on 3/8/24, patient was sent to IR on 3/15/24 for replacement however tract was not salvageable. Patient was sent back to facility without enteral access or acceptable nutrition plan and no planned procedure date for G tube replacement patient only able to tolerate small amounts of by mouth intake since 3/8/24 resulting in 15 lbs (pounds) weight loss as patient has been without necessary tube feeding to maintain weight for 20 days. Patient was found to have lost about 15 lbs and appeared dry hence the referral to the emergency department sodium level 165. During an interview on 5/2/24 at 9:44 A.M., the Medical Director said he was relying on nursing staff to communicate with him regarding Resident #95's care. The MD said the nursing staff had made him aware that the Resident's intake had been adequate since the g-tube had dislodged on 3/8/24. He further said there was a delay in his part, and he should have sent the Resident to the hospital sooner. The MD said when he saw the Resident on 3/25/24 the Resident was dehydrated, his/her ability to swallow had declined and IV fluids started two days before the Resident was transferred to the hospital. The MD said the Resident should have been monitored closely due to being at high risk for dehydration. During an interview on 5/2/24 at 11:26 A.M., the Registered Dietician (RD) said she encouraged nursing staff to provide more fluids to the Resident to replace the hydration that the Resident would have received from the feeding tube. She further said since the Resident had required tube feeding 100 percent for his/her nutritional support and hydration, he/she should have monitored closely as an at risk for dehydration. The RD said she advocated for the tube feed to be replaced sooner. During an interview on 5/2/24 at 12:39 P.M., the Director of Nursing said the risk team did not follow the Resident as he/she resided in the short-term unit. She further said the RD should have monitored the Resident closely. The Director of Nursing said that her expectation is that the RD would be the one to make recommendations to the MD.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was admitted to the Facility for a short term respite stay, and had a history of a seizure disorder for which he/she required administration of anticonvulsant/anti-seizure medication, the Facility failed to ensure nursing notified the physician when his/her anticonvulsant/anti-seizure medication was not administered, per physician's orders. Resident #2's admission physician's orders indicated to administer Vimpat (anticonvulsant medication) 100 milligrams (mg) twice daily. However, the physician was not notified that the Vimpat had not been delivered from the pharmacy, that his/her scheduled doses were omitted (not administered) by nursing, and as a result, he/she missed 10 consecutive doses of the medication. On the day of Resident #2's planned discharge, he/she exhibited signs and symptoms of a change in condition with a decline in status, and experienced seizure activity. Findings include: The Facility Policy, titled Change in a Resident's Condition or Status, dated 02/2021, indicated staff would promptly notify the resident, his/her attending physician, and the resident's representative of changes in the resident's medical condition, and document in the resident's medical record any information relative to changes in the resident's medical condition. The Facility's Internal Investigation Report, undated, indicated Resident #2 was admitted to the Facility for a five-day period (Respite Stay), and on the day of admission Nurse Practitioner #1 did not write a prescription for his/her Vimpat. The Investigation Report indicated that during this time, four nurses that were assigned to provide his/her care, did not administer Resident #2's Vimpat, and all of them assumed there was a delay in receiving it from the pharmacy. Resident #2 was admitted to the Facility in January 2023, diagnoses included epilepsy (seizure disorder), neoplasm (tumor) of the brain, pleural effusion (fluid surrounding the lung), and obstructive uropathy. Review of Resident #2's Medication Review Report, dated 01/18/23, and signed by Nurse Practitioner (NP) #1 on 01/20/23, indicated Resident #2 physician's orders for medications included the administration of the following; -Vimpat (anticonvulsant, used for seizures) tablet, 100 mg by mouth two times a day. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #2's Medication Administration Record (MAR) for January 18, 2023 through January 23 2023 indicated he/she had physician's orders to be administered Vimpat 100 mg, two times a day, at 9:00 A.M., and 9:00 P.M., however Vimpat was not administered on: -01/18/23 9:00 P.M. -01/19/23 9:00 A.M. and 9:00 P.M. -01/20/23 9:00 A.M. and 9:00 P.M. -01/21/23 9:00 A.M. and 9:00 P.M. -01/22/23 9:00 A.M. and 9:00 P.M. -01/23/23 9:00 A.M. dose. -(ten consecutive doses). Further review of Resident #2's MAR related to the Vimpat indicated nurses documented the following: -Other, see nurse's notes -absence of condition/not applicable. Review of Resident #2's Nurse Progress Notes related to documentation regarding his/her Vimpat medication omission indicated the following: -Nurse Progress Note, dated 01/18/23, indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/19/23, timed 11:19 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/19/23, timed 9:08 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/20/23, timed 2:56 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/20/23, timed 10:13 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/21/23, indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/22/23, timed 10:16 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/23/23, indicated Resident #2's Vimpat was on order from the pharmacy. Further review of Resident #2's medical record indicated there was no documentation to support that nursing staff notified Resident #2's physician regarding the missed doses of Vimpat, that the physician had been notified it had not been delivered from the pharmacy, or that nursing had contacted the pharmacy to see when the Vimpat would be delivered. The Situation Background Appearance Review and Notify (SBAR) Note, dated 1/23/22, indicated Resident #2 had a change in condition, was stiff and weak, and needed more help with Activities of Daily Living (ADLs). During interview on 02/17/23 at 2:35 P.M., Nurse #4 said she had been assigned to provide care for Resident #2 several times during his/her admission. Nurse #4 said she knew Resident #2's Vimpat was unavailable on several occasions, said she called the pharmacy, was told the Vimpat was going to be delivered, but said she did not notify Resident #2's physician or Nurse Practitioner of the omitted doses. Nurse #4 said that on 01/21/23 another nurse asked her where Resident #2's Vimpat was, so she called the pharmacy again, and was told that the pharmacy had not received the prescription (required) for it. Nurse #4 said she told the other nurse that a prescription was needed, but that she did not call the physician or NP herself, and left the Facility as her shift was over. During interview on 02/13/23 at 2:10 P.M., Nurse #3 said she was assigned to Resident #2 for the first time on 01/23/23. Nurse #3 said Resident #2 was scheduled to be discharged home that day and she noticed his/her Vimpat was unavailable. Nurse #3 said she notified Unit Manager #1 and Resident #2's Hospice Nurse that he/she did not receive Vimpat that day. Nurse #3 said she did not review Resident #2's MAR for the previous days and said she was unaware that Resident #2 had not received 10 consecutive doses of his/her Vimpat. Nurse #3 said Certified Nurse Aide (CNA) #1, who was familiar with Resident #2, told her Resident #2 was different that morning and needed more help with his/her ADLs. During interview on 02/14/23 at 2:22 P.M., Certified Nurse Aide (CNA) #1 said that on 01/23/23 Resident #2 needed more help than usual with ADLs. CNA #1 said Resident #2 was usually able to walk and help with washing, but that day she (CNA #1) needed help from another staff member to transfer him/her. CNA #1 said she found Resident #2 was too weak to walk, needed a wheelchair to move around the room, and was unable to help with washing him/herself. CNA #1 said she notified Nurse #3 of Resident #2's change. During interview on 02/14/23 at 10:58 A.M., Unit Manager #1 said that on 01/18/23, she sent a text message to NP #1 to let her know that Resident #2 was a new admission and needed prescriptions, but did not specifically tell NP #1 that they needed a written prescription sent to the pharmacy for Vimpat, and said she did not see NP #1 after she texted her that day. Unit Manager #1 said she was unaware until 1/23/23 that Resident #2's Vimpat had not arrived from the pharmacy and that there was no prescription written, until right before he/she was discharged from the Facility. During interview on 02/14/23 at 10:58 A.M., Nurse Practitioner (NP) #1 said she was in the Facility on 01/18/23 when Resident #2 was admitted , and said she signed his/her orders, but was unaware that he/she needed a prescription written and sent to the pharmacy for Vimpat. NP #1 said the nurses did not call her any time during his/her admission to notify her of any medication omissions until after Resident #2 had been discharged . NP #1 said she expected that if a medication was not available Nursing would notify the physician or NP and obtain new orders. NP #1 said missing Vimpat put Resident #2 at higher risk for seizure activity and said she would not have discharged him/her home that day as planned. During interview on 2/17/23 at 10:05 A.M., Nurse Practitioner (NP) #2 said she was on call on 01/23/23 and was notified via text message by Unit Manager #1 that Resident #2 was being discharged that day following a five-day respite stay at the Facility, had not received his/her Vimpat that day, and it appeared as though he/she might have had a seizure. NP #2 said she could not recall if she had a phone conversation with nursing regarding Resident #2, and said she was not made aware that he/she had not received 10 consecutive doses of Vimpat. NP #2 said she would have provided orders for and directed nurses to administer another anticonvulsant/antiseizure medication, and would have asked Resident #2's family if they would want him/her transferred to the Hospital for an evaluation. During interview on 02/14/23 at 1:26 P.M., the Director of Nurses (DON) said that nursing staff were expected to notify the physician or NP of any medication omission, but they determined that nurses had not notified the physician or NP of any of Resident #2's omitted medication doses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was admitted for short term respite care, and whose diagnoses included a seizure disorder, the Facility failed to ensure he/she was free of significant medication error, when he/she was not administered Vimpat, (anticonvulsant medication) 100 milligrams (mg) twice daily, per physician's orders. Resident #2 missed 10 consecutive doses of Vimpat, and although nursing documented it was unavailable, nurses assigned to care for Resident #2 did not notify the physician to report the medication was not being administered or to obtain additional orders related to the omitted doses of Vimpat. On the day of Resident #2's discharge, he/she exhibited signs and symptoms of a change in condition with a decline in status, and nursing reported he/she exhibited signs and symptoms of seizure activity prior to discharge. The Hospice report dated [DATE], indicated Resident #2 had active seizures upon arrival at home that morning. Findings include: The Facility Policy, titled Adverse Consequences and Medication Errors, dated 4/2014, indicated: -A medication error was defined as the preparation or administration of drugs or biological's which was not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principals of the professional providing services. -An Example of a medication error included omission (a drug was ordered but not administered). -In the event of a significant medication related error, immediate action would be taken. Significant was defined as requiring treatment with prescribed medication, resulting in cognitive deterioration or impairment, was life threatening, or resulted in death. -The attending physician would be notified promptly of any significant error, and new orders would be implemented, the resident would be monitored closely, as directed. The Facility Policy, titled, Medication Administration Errors, dated 01/2015, indicated a medication administration error occurred when a resident received a dose of medication that deviated from the original physician's order, and included omission. All medication administration errors may be reported immediately to the physician responsible for the resident and the physician would provide instruction to the nurse regarding the care of the resident as a result of the medication error. Resident #2 was admitted to the Facility in [DATE], diagnoses included epilepsy (seizure disorder), neoplasm (tumor) of the brain, pleural effusion (fluid surrounding the lung), and obstructive uropathy. Review of Resident #2's Medication Review Report, dated [DATE], and signed by Nurse Practitioner (NP) #1 on [DATE], indicated Resident #2 had the following physician's orders: -Vimpat (anticonvulsant, used to treat seizures) tablet, 100 mg by mouth two times a day. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #2's Medication Administration Record (MAR) for [DATE] through [DATE] indicated he/she had physician's orders to be administered Vimpat 100 mg, two times a day at 9:00 A.M., and 9:00 P.M., however Vimpat was not administered at all during his/her admission, on the following dates and times; -[DATE] 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. dose. -(ten consecutive doses). Further review of Resident #2's MAR related to the Vimpat indicated nurses documented the following: -Other, see nurse's notes -absence of condition/not applicable. Review of Resident #2's Nurse Progress Notes related to documentation regarding his/her Vimpat medication omission indicated the following: -Nurse Progress Note, dated [DATE], indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 11:19 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 9:08 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 2:56 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 10:13 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 10:16 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], indicated Resident #2's Vimpat was on order from the pharmacy. Further review of Resident #2's medical record indicated there was no documentation to support that nursing staff contacted and notified Resident #2's physician regarding the missed doses of Vimpat or that nursing had contacted the pharmacy to see when the Vimpat would be delivered. The Situation Background Appearance Review and Notify (SBAR) Note, dated [DATE], indicated Resident #2 had a change in condition, was stiff and weak, and needed more help with Activities of Daily Living (ADLs). The Medication Error Report, dated [DATE], indicated Resident #2 had a physician's order for Vimpat 100 mg by mouth twice daily which was never received from the pharmacy, and nursing staff never reported to the physician or NP that the medication was unavailable. The Facility's Internal Investigation Report, undated, indicated Resident #2 was admitted to the Facility for a five day period (Respite Care), and on the day of admission Nurse Practitioner #1 did not write a prescription (required by the pharmacy in order to dispense) for Vimpat. The Investigation Report indicated that during this time, four nurses (that were assigned to care for him/her) did not administer Resident #2's Vimpat, and all of them assumed there was a delay in receiving it from the pharmacy. During interview on [DATE] at 2:35 P.M., Nurse #4 said she had been assigned to provide care for Resident #2 several times during his/her admission. Nurse #4 said she knew Resident #2's Vimpat was unavailable on several occasions, said she called the pharmacy, was told the Vimpat was going to be delivered, and said she did not notify Resident #2's physician or Nurse Practitioner of the omitted doses. Nurse #4 said that on [DATE] another nurse asked her where Resident #2's Vimpat was, so she called the pharmacy, and was told that the pharmacy had not received the prescription for it. Nurse #4 said she told the other nurse that a prescription was needed, but did not call the physician or NP herself, and left the Facility as her shift was over. During interview on [DATE] at 2:10 P.M., Nurse #3 said she was assigned to Resident #2 for the first time on [DATE]. Nurse #3 said Resident #2 was scheduled to be discharged home that day and she noticed his/her Vimpat was unavailable. Nurse #3 said she notified Unit Manager #1 and Resident #2's Hospice Nurse that he/she did not receive the Vimpat that day. However, Nurse #3 said she did not review Resident #3's MAR for the previous days and said she was unaware that Resident #2 had not received 10 consecutive doses of his/her Vimpat. Nurse #3 said Certified Nurse Aide (CNA) #1, who was familiar with Resident #2, told her Resident #2 was different that morning and needed more help with his/her Activity's of Daily Living (ADLs). During interview on [DATE] at 2:22 P.M., Certified Nurse Aide (CNA )#1 said that on [DATE] Resident #2 needed more help than usual with ADLs. CNA #1 said Resident #2 was usually able to walk and participate with washing, but that day she needed another staff member to help to transfer him/her, CNA #1 said she found Resident #2 was too weak to walk and needed a wheelchair to move around the room, and was unable to help with washing him/herself. CNA #1 said she notified Nurse #3. During interview on [DATE] at 10:58 A.M., Unit Manager #1 said that on [DATE], she sent a text message to NP #1 to let her know that Resident #2 was a new admission and needed prescriptions. Unit Manager #1 said in the text to NP #1 she did not specifically say they needed a prescription for Vimpat, and said she did not see NP # 1 after that on that day. Unit Manager #1 said she was not aware that Resident #2's Vimpat had not arrive from the pharmacy or that there had not been a prescription (required by pharmacy in order to dispense) written until [DATE], right before he/she was discharged from the Facility. Unit Manager #1 said she was notified by Nurse #3 on [DATE] that Resident #2 was weaker than usual, and that he/she might have had a seizure that morning. During interview on [DATE] at 10:58 A.M., Nurse Practitioner (NP) #1 said she was in the Facility on [DATE] when Resident #2 was admitted , and said she signed his/her orders, but was unaware that he/she needed a written prescription sent to the pharmacy for Vimpat. NP #1 said nursing staff did not call her any time during his/her admission to notify her of any medication omissions until after Resident #2 had been discharged home. NP #1 said she expected that if a medication was not available nursing staff would notify the physician or NP and obtain new orders. NP #1 said missing Vimpat put Resident #2 at higher risk for seizure activity, and said she would not have discharged him/her home that day as planned. During interview on [DATE] at 10:05 A.M., Nurse Practitioner (NP) #2 said she was on call on [DATE], and was notified via text message by Unit Manager #1 that Resident #2 was scheduled to be discharged home that day following a five day respite stay at the Facility, had not received his/her Vimpat, and it appeared as though he/she might have had a seizure. NP #2 said she could not recall if she had a phone conversation with staff regarding Resident #2, but said she was not made aware that he/she had not received 10 consecutive doses of Vimpat. NP #2 said she would have provided orders for and instructed nurses to administer an appropriate alternative medication, and would have asked Resident #2's family if they would want him/her transferred to the Hospital for an evaluation. Review of the Hospice Report, dated [DATE], indicated that on [DATE], Resident #1 was discharged home, and assessed as having increased lethargy and weakness, and family reported he/she had an active seizure upon arrival at home. The Hospice Report indicated Resident #2 died early the next morning on [DATE]. During interview on [DATE] at 1:26 P.M., the Director of Nurses (DON) said that nursing staff were expected to notify the physician or NP of any medication omission, but their investigation determined that nursing had not notified the physician or NP of any of Resident #2's omitted Vimpat doses. The DON said if medications were not yet delivered from the pharmacy, nursing staff were expected to check if the medication was available in the Omnicell (automated pharmaceutical dispensing machine), and notify the pharmacy.