**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to ensure a physician and/or the physician assistant (PA) provided supervision and oversight for the care of one Resident (#40) with a known history of an organ transplant, out of a total sample of 18 residents, who required the daily use of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection). Specifically, the physician and PA failed to: 1. Identify that tacrolimus was discontinued after a recent hospitalization, resulting in a total of 40 missed doses; and 2. Address and intervene on abnormal tacrolimus level laboratory values, leading to the Resident's emergent hospitalization for organ transplant rejection surveillance and medication management. Findings include: Review of the facility's policy titled Labs and Diagnostics, revised 4/2022, indicated, but was not limited to, the following: -Assessment and Recognition 1. The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. -Physician Responses 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response. b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. When necessary to help explain clinical decisions, a physician or mid-level practitioner should document the basis for conclusions about how the results were addressed; for example, at the next scheduled or interim visit. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant. Review of the Minimum Data Set (MDS) assessment, dated 3/30/25, indicated Resident #40 was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 15 out of 15, was dependent on staff for activities of daily living, and had diagnoses including heart failure and organ transplant. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Resident #40's tacrolimus level laboratory result, obtained via a blood draw from the Resident on 2/26/25, was 6.4 nanograms per milliliter (ng/ml). The Resident's goal tacrolimus level was 4-6 ng/ml -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. -A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus. Review of Resident #40's current Physician's Orders indicated the following: - Fax tacrolimus level results to [fax number redacted] every month between the 7th and the 11th of every month for immunosuppressive therapy (order start date 7/10/24). Further review indicated the fax number was directed to Resident #40's cardiologist's office. -No tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25. -Review of the current Physician's Orders failed to indicate an order for a tacrolimus level on 3/3/25 as indicated in the Resident's hospital After Visit Summary 2/27/25. Review of Resident #40's laboratory results indicated, but was not limited to, the following: -On 3/6/25, the Resident had a tacrolimus level drawn (three days after the recommended draw date). The tacrolimus level resulted low at 1.2 ng/ml on 3/11/25 at 4:06 P.M. and were marked as reviewed by the PA on 3/13/25 at 12:45 P.M. There was no additional documentation or new orders from the PA entered in the Resident's record at that time. Review of Resident #40's February 2025 and March 2025 Medication Administration Record indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Resident #40's Progress Notes indicated, but was not limited to, the following: -On 2/27/25, a progress note was entered by the PA. The note indicated that the Resident had a prolonged hospitalization for CHF exacerbation and urinary tract infection and that the Resident's history was significant for organ transplant. The medication list, included in the PA's progress note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The PA's note failed to identify the change in the Resident's tacrolimus regimen to include the additional dose of 3 mg each day at 9 P.M. Additionally, the PA's progress note failed to indicate the follow-up tacrolimus level monitoring to be drawn on 3/3/25, as recommended by the hospital. -On 2/28/25, a progress note was entered by the physician. The physician documented in her note that the Resident was transferred to the hospital on February 22 and returned to the facility on February 27. The physician indicated the Resident was hospitalized due to change in mental status, nausea, and tremors and was treated with antibiotics for a urinary tract infection. The physician indicated the Resident was on immunosuppression with prednisone and tacrolimus and was at high risk of complications and infections. The medication list, included in the physician's note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The physician's note failed to identify the change in the Resident's tacrolimus regimen to include the additional dose of 3 mg each day at 9 P.M. Additionally, the physician's progress note failed to indicate the follow-up tacrolimus level monitoring to be drawn on 3/3/25, as recommended by the hospital. -On 3/19/25, a progress note was entered by the physician. The physician's note indicated the nursing notes, vital signs, and medications available in the Resident's electronic health record (EHR), prior external notes, and hospital discharge summary were reviewed. The physician documented that the Resident had received an organ transplant in 2021 and that she was contacted by the Cardiology RN in regard to Resident #40's low tacrolimus level of 1.2 ng/ml. The note indicated the Cardiology RN had discussed the Resident's medication regimen with staff at the facility and it appeared that the Resident had missed his/her tacrolimus since he/she was readmitted to the facility on [DATE] and was supposed to receive tacrolimus twice daily. The physician confirmed with nursing staff that the Resident had not received the tacrolimus and was later informed that the Cardiology RN had called the facility and recommended the Resident be transferred to the hospital for intravenous steroid treatment. Despite the documentation written in the physician's progress note, the medication list included in the progress note again indicated the Resident was taking tacrolimus 1 mg two capsules in the morning and provided no indication of the 9 P.M. tacrolimus dose the Resident should have received but did not. Review of documentation received from Resident #40's consulting cardiology team indicated that on 3/19/25, the Cardiology RN spoke with the Resident's physician at the facility and the physician was unaware of the critical tacrolimus lab value and discontinuation of tacrolimus. During a telephonic interview on 5/7/25 at 1:01 P.M., the physician said the Resident's tacrolimus didn't make it onto his/her medication list at the facility. The physician said the medication was to be used to prevent organ rejection as the Resident had received an organ transplant. The physician said she was made aware of the omission on 3/19/25 when she was informed by the Cardiology RN at the hospital. The physician could not recall being contacted about Resident #40's tacrolimus lab results on 3/11/25, despite being reviewed by the PA. During a telephonic interview on 5/7/25 at 1:39 P.M., the PA said he was aware of the medication error and had seen Resident #40 in between his/her readmission to the facility on 2/27/25 and transfer back to the hospital on 3/19/25. The PA said he could not recall when he was made aware of the medication error but if he had been aware of it before the Resident was transferred back to the hospital, he would have restarted the medication at that time. The PA said that he was aware the Resident's tacrolimus level had resulted low on 3/11/25, and said the results should be faxed to cardiologist for review. The PA said he was unaware if the results had been sent to the cardiologist because that is something the nursing staff would do and he did not follow up with nursing to ensure the results were communicated to the Resident's cardiologist. The PA further said he was unaware the Resident had not received the medication at the time the lab value was obtained. During a subsequent interview with record review on 5/8/25 at 1:48 P.M., the PA said he did not recall the date that he became aware of Resident #40's abnormal tacrolimus level in March 2025, but thought it was around the same time the Resident went out to the hospital and the nurses called him for the order to transfer the Resident. The PA said he reviewed the lab but would not make changes to the Resident's tacrolimus regimen despite abnormal tacrolimus levels because the Resident's tacrolimus labs and dosing are managed by the cardiology office. The PA said the results of the Resident's labs drawn at the facility are forwarded to the cardiology office by the facility staff and the cardiologist will review and make any new dosing recommendations, which he or the Resident's attending physician would then review. Further review of Resident #40's medical record failed to indicate that the PA or physician adequately reviewed the hospital discharge/cardiology recommendations or followed up with nursing to ensure the resident's medical care was supervised by the facility's physician services. Refer to F760

Based on observation, record review, and interviews, the facility failed to ensure licensed nursing staff were competent in immunosuppressant drug therapy resulting in: a. failure to identify the adverse discontinuation of a necessary immunosuppressant medication (tacrolimus) for the prevention of organ rejection for one Resident (#40) in a sample of 18 residents; and b. failure to communicate with the practitioner about abnormally low tacrolimus level laboratory results for Resident #40, readmitted to the facility with a known history of heart transplant, resulting in emergent hospitalization in March 2025 for transplanted organ rejection surveillance and medication regimen adjustments. Findings include: Review of the Facility Assessment, updated 4/25/25 and reviewed by the QAPI Committee on 4/28/25, indicated: -Services and Care We Offer Based on our Residents' Needs Medications: Awareness of any limitations of administering medications Administration of medications that residents need Management of medical conditions: Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure -Staff training/education and competencies Once the new staff member has completed the classroom orientation, they are partnered with a member to learn the specifics of their role. The mentor trains and completes a competency check list to assure the staff has received the proper training and can perform the necessary tasks related to their role and according to [Facility Name's] standards. Once competency is evaluated and successfully completed, they can assume their position autonomously. If any deficits are identified, additional training is provided. The staff is then provided with regular in-service opportunities and evaluations at least annually, to identify any additional dementia training, and a corporate compliance review. Review of the facility's policy titled Change in Condition in a Resident Status, effective 3/2017, indicated, but was not limited to, the following: -The Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: *A need to alter the resident's medical treatment significantly *Abnormal laboratory reports *A need to transfer the resident to a hospital/treatment center Review of the facility's policy titled Labs and Diagnostics, revised 4/2022, indicated, but was not limited to, the following: -Review by Nursing Staff 1. A nurse will review all results. -Deciding How Urgently to Contact the Physician 1. A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition. 2. A nurse will try to determine whether the test was done a. As a routine screen or follow-up; b. To assess a condition change or recent onset of signs and symptoms; or c. To monitor a drug level. -Identifying Situations that Warrant Immediate Notification Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results. 1. The physician has requested to be notified as soon as a result is received. 2. The result is something that should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors). -Determining the Reason for Testing 1. If the results do not meet the preceding criteria for immediate notification, then the nursing staff will review why the test was obtained, as well as the resident's current clinical status including the presence of any signs or symptoms. -Options for Physician Notification 1. A physician can be notified by phone, fax, voicemail, e-mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff). a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. -Physician Responses 1. Time frames. A physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. a. A physician should respond within one hour regarding a lab result requiring immediate notification . and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response b. If the Attending or Covering Physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and organ transplant. a. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. Review of documentation received from Resident #40's consulting heart failure team indicated at time of discharge from the hospital back to the facility on 2/27/25, the Resident was prescribed tacrolimus 1 mg - Take 2 mg daily at 9 A.M. and take 3 mg daily at 9 P.M. Review of Resident #40's Medication Reconciliation, dated 2/27/25, indicated the Resident's list of medications from the facility prior to hospitalization (his/her home medication list) and the Discharge Summary were reviewed and indicated that potential clinically significant medication issues were identified. The document failed to indicate what the discrepancies were or the provider's resolutions for the discrepancies. -On 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated the order was subsequently discontinued on 2/27/25 at 6:05 P.M. Review of Resident #40's Physician's Orders indicated no tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25. Review of Resident #40's February 2025 and March 2025 Medication Administration Records (MAR) indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Nurse #1 and Nurse #2's staff education files during the extended survey on 5/8/25 failed to indicate there was previous education completed on immunosuppressant medication. Nurse #2 was working on Resident #40's unit and assigned to Resident #40's care during survey. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Director of Nursing (DON) at the facility from 12/24/24 until the new DON started at the facility on 3/14/25. Regional Nurse Consultant #1 said that when a resident is admitted /readmitted to the facility, the nurse entering the resident's physician's orders reviews the hospital discharge records and medications and then reviews those medications with the resident's provider at the facility. Regional Nurse Consultant #1 said there is a Medication Reconciliation assessment completed in the electronic health record by the nurse after the medications have been reviewed with the provider. Regional Nurse Consultant #1 said if there is a medication that they recognize a resident is no longer prescribed, they need to make note of it. During an interview on 5/7/25 at 3:22 P.M., Nurse #2, Nurse #3, and Nurse #4, working on the unit where Resident #40 resides, said they could not recall any education pertaining to Resident #40 or his/her immunosuppressant medication regimen. During an interview on 5/8/25 at 11:36 A.M., the surveyor reviewed the facility's education binder with the SDC and she said that records of all in-service training she conducted were in the binder. In-service training records in the education binder failed to include in-service training on immunosuppressant medication use/monitoring prior to 3/18/25. b. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus. Review of documentation received from Resident #40's consulting heart failure team indicated, but was not limited to, the following: -The Resident's tacrolimus level on 2/26/25 was 6.4 ng/ml (goal level was 4-6 ng/ml). A tacrolimus level drawn 2/27/25 remained pending at time of discharge and the facility was to send a tacrolimus level on 3/3/25 to the heart failure team for follow-up and dosing recommendations. Review of Resident #40's Physician's Orders failed to indicate that an order was obtained for a tacrolimus level on 3/3/25 related to abnormal tacrolimus level and tacrolimus dosing adjustments during hospitalization as indicated in the Resident's hospital After Visit Summary 2/27/25. Review of Resident #40's medical record indicated that on 3/6/25, the Resident had a tacrolimus level drawn (three days after the recommended draw date). The tacrolimus level resulted low at 1.2 ng/ml on 3/11/25 at 4:06 P.M. and were marked as reviewed by the Physician Assistant (PA) on 3/13/25 at 12:45 P.M. The medical record failed to indicate the lab values were received by or reviewed with the heart failure team for recommendations for ongoing dosing of tacrolimus prior to 3/18/25. Review of Resident #40's Progress Notes indicated: -On 3/19/25 at 3:05 P.M., the facility nurse documented that the Resident's cardiologist requested the Resident be transferred to the emergency room at the hospital affiliated with the consulting heart failure team due to the Resident not having immunosuppressant drugs for the last two weeks. The Progress Note indicated the Resident was stable at the time of transfer. Review of the facility's education binder on 5/8/25 failed to indicate there was in-service education conducted on provider notification of abnormal lab results or communication with consulting providers. Review of Nurse #1 and Nurse #2's staff education files during the extended survey on 5/8/25 failed to indicate there was previous education completed on laboratory reporting. Nurse #1 and Nurse #2 currently work on Resident #40's unit. On 5/7/25, the surveyor attempted a phone interview with former First Floor Unit Manager #1, the nurse that admitted Resident #40. She has since resigned from the facility and did not return the surveyor's call. During an interview on 5/7/25 at 3:22 P.M., Nurse #2, Nurse #3, and Nurse #4, working on the unit where Resident #40 resides, said they could not recall any education pertaining to Resident #40. During an interview on 5/8/25 at 11:36 A.M., the surveyor reviewed the facility's education binder with the SDC and she said that records of all in-service training she conducted were in the binder. In-service training records in the education binder failed to include in-service training on immunosuppressant medication use/monitoring or laboratory reporting prior to 3/18/25. Refer to F760

Based on record review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, an admission Medication Regimen Review (AMRR) was completed by the Consultant Pharmacist upon readmission to the facility and an irregularity was identified. Specifically, the Consultant Pharmacist failed to identify the discontinuation of Resident #40's immunosuppressant medication and, as a result, Resident #40 (a heart transplant recipient) missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization. Findings include: Review of the facility's policy titled Reconciliation of Medications on Admission, revised 3/22, indicated, but was not limited to, the following: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. -Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. -Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (Medication Administration Record) (if applicable), and the admitting orders (sources). -List the dose, route, and frequency for all medications. -Review the list carefully to determine if there are discrepancies/conflicts. Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant. Review of the Minimum Data Set (MDS) assessment, dated 3/30/25, indicated Resident #40 was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 15 out of 15, was dependent on staff for activities of daily living, and had diagnoses including heart failure and organ transplant. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Resident #40's tacrolimus level laboratory result, obtained via a blood draw from the Resident on 2/26/25, was 6.4 nanograms per milliliter (ng/ml). The Resident's goal tacrolimus level was 4-6 ng/ml -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. -A tacrolimus level should be obtained and sent to the hospital's heart failure team on 3/3/25 and the heart failure team would provide recommendations for ongoing dosing of tacrolimus. Review of Resident #40's Medication Reconciliation, dated 2/27/25 and completed by nursing, indicated the Resident's list of medications from the facility prior to hospitalization (his/her home medication list) and the Discharge Summary were reviewed and indicated that potential clinically significant medication issues were identified. The document failed to indicate what the discrepancies were or the provider's resolutions for the discrepancies. Review of Resident #40's Physician's Orders indicated that on 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated an order was entered to discontinue the medication on 2/27/25 at 6:05 P.M. Review of Resident #40's medical record failed to indicate that an AMRR had been completed by a Consultant Pharmacist after the Resident returned to the facility from the hospital on 2/27/25, and there was no indication of a pharmacy review of Resident #40's record from the date of his/her return to the facility until 3/8/25. Review of Resident #40's February 2025 and March 2025 Medication Administration Record indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Resident #40's Progress Notes indicated: -On 2/27/25, an Order Note entered by nursing indicated an order for Tacrolimus 1 mg - Give 3 capsules by mouth at bedtime and 2 capsules by mouth one time a day was entered and was outside of the recommended dose or frequency (the usually dosing regimen per the note is 3 to 46.5386 capsules two times per day) -On 2/27/25 at 11:48 P.M., the nurse at the facility documented that the Resident had been treated at the hospital for altered mental status and his/her medications were confirmed by the PA. -The Progress Notes failed to indicate that the physician's order for tacrolimus was discontinued on 2/27/25 or why the medication was discontinued. -On 3/8/25, the Resident's medication regimen was reviewed by the pharmacy consultant and no irregularities were noted. Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated that on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. A Performance Improvement Plan (PIP) attached to the Medication Incident and Discrepancy Form indicated medication was not administered for a resident on tacrolimus and the root cause was the medication was entered in the electronic health record incorrectly as it was entered as a one-time order. The Medication Incident and Discrepancy Report Form and PIP failed to indicate that the pharmacy's AMRR had not been completed after Resident #40's readmission to the facility on 2/27/25 or that the Consultant Pharmacist's monthly MRR did not identify the discontinuation of the Resident's immunosuppressant medication. During an interview on 5/7/25 at 7:58 A.M., Resident #40 said that he/she had been sent to the hospital at the end of March because he/she had missed doses of his/her anti-rejection medication and the transplant doctor wanted him/her to be monitored. Resident #40 said he/she underwent testing at the hospital and everything was okay and he/she returned to the facility. Resident #40 said he/she did not know how much medication was missed or why. During a telephonic interview on 5/7/25 at 11:35 A.M., the Consultant Pharmacist said that a different pharmacist is assigned to review admission/readmission MRRs. The Consultant Pharmacist said that he cannot recall being notified of medication errors at the facility. During an interview on 5/7/25 at 1:08 P.M., the Regional Pharmacy Manager said the AMRRs are not conducted by the Consultant Pharmacist who conducts the routine monthly Medication Regimen Reviews (MRRs) and that there is an additional Consultant Pharmacist who only completes the AMRRs for the facility. The Regional Pharmacy Manager said that he had conducted an audit and concluded that the AMRRs were not completed consistently in February and March 2025. The Regional Pharmacy Manager said that the AMRRs should be completed within 72 hours of a resident's admission/readmission to the facility. The Regional Pharmacy Manager said that Resident #40 had returned to the facility on 2/27/25, but no AMRR had been completed within 72 hours of his/her readmission. The Regional Pharmacy Manager said that when he reviewed Resident #40's record, a tacrolimus order was in place for only one day and there was a discrepancy between the hospital discharge orders and facility's admission orders for the Resident. The Regional Pharmacy Manager said that had an AMRR been completed, this discrepancy would have been identified at that time. The Regional Pharmacy Manager said that tacrolimus is a medication used to prevent organ rejection and blood levels of the medication are monitored routinely to ensure dosing of the medication is therapeutic. The Regional Pharmacy Manager said Resident #40 had missed 20 days of his/her twice daily tacrolimus doses and that this put the Resident at higher risk for organ rejection. During an interview on 5/7/25 at 4:52 P.M., Regional Nurse Consultant #1 said that she is copied on an email from the pharmacy containing a report of all Medication Regimen Reviews completed for the facility when they are completed. Regional Nurse Consultant #1 said that she was made aware of the inconsistent completion of AMRRs in February and March 2025 by the Regional Pharmacy Manager on 5/7/25. During a subsequent telephonic interview on 5/08/25 at 9:00 A.M., the Regional Pharmacy Manager said that there are consultant pharmacists who complete the monthly medication regimen reviews (MRRs) and other consultant pharmacists that only complete the AMRRs. The Regional Pharmacy Manager said that when he receives the AMRRs, he reviews a report called the Action Summary from the facility's electronic health record and reviews the residents' date of admission/readmission and the date the AMRR was completed to ensure AMRRs are completed within 72 hours of admission/readmission. The Regional Pharmacy Manager said that when he was doing the audit for the facility at the end of March, he noted that the AMRRs had not been completed as required in February and March 2025. The Regional Pharmacy Manager said that the facility's corporate nursing leadership (Regional Nurse #3) was notified of the issue at the beginning of April 2025. The surveyor attempted to contact Regional Nurse #3, but she was unable to be reached. Refer to F760

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interviews, the facility failed to ensure for one Resident (#40), out of a total sample of 18 residents, to ensure he/she was free from a significant medication error when the Resident's immunosuppressant medication was discontinued in error. As a result, Resident #40 missed 40 doses of tacrolimus (Prograf, an immunosuppressant medication used to prevent transplanted organ rejection) and required emergent hospitalization and medication adjustments during and after hospitalization. Findings include: Review of the facility's policy titled Reconciliation of Medications on Admission, revised 3/22, indicated, but was not limited to, the following: -Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. -Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. -Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (Medication Administration Record) (if applicable), and the admitting orders (sources). -List the dose, route, and frequency for all medications. -Review the list carefully to determine if there are discrepancies/conflicts. Review of the facility's policy titled Aftercare of Heart Transplant, effective 4/17, indicated, but was not limited to, the following: -After a heart transplant, a comprehensive aftercare plan is crucial for long-term success and involves ongoing monitoring for rejection, infection, and medication side effects, as well as adherence to lifestyle modifications and regular follow-up appointments. This includes taking immunosuppressant medications, adhering to a prescribed exercise program, and maintaining a healthy diet. -This policy applies to all adult patients who have undergone a heart transplant and are currently more than three years post-transplant. -All heart transplant recipients post-transplant must receive individualized, evidence-based follow-up care focusing on immunosuppressive management, cardiovascular health, infection surveillance, malignancy screening, and psychosocial well-being. -Immunosuppressive Management *Maintain lowest effective dose of maintenance immunosuppression (e.g. tacrolimus, mycophenolate, prednisone) *Monitor for long-term side effects: nephrotoxicity (deterioration in kidney function due to toxic substances), hypertension (high blood pressure), diabetes, dyslipidemia (abnormal levels of fats in the blood) *Evaluate for medication adherence at every visit -Documentation and Communication *All assessments and interventions must be documented in the patient's electronic health record (EHR). *Coordinate care with primary care providers and other specialists. -Quality Assurance *Annual review of resident outcomes (graft survival, complications, hospitalizations) *Compliance audits on follow-up scheduling and lab monitoring Resident #40 was admitted to the facility in January 2024 with diagnoses including stroke, heart failure, and heart transplant. Review of the Minimum Data Set (MDS) assessment, dated 3/3/25, indicated Resident #40 was cognitively intact, as evidenced by a Brief Interview for Mental Status score of 15 out of 15, was dependent on staff for activities of daily living, and had diagnoses including heart failure and organ transplant. Review of Resident #40's medical record indicated that Resident #40 was hospitalized in February 2025. Review of the hospital After Visit Summary, dated 2/27/25, indicated, but was not limited to, the following: -Resident #40 was admitted to the hospital in February 2025 for heart failure exacerbation and some of his/her medications had changed, including tacrolimus. -Upon discharge, the Resident should start taking tacrolimus 2 milligrams (mg) each day at 9 A.M. and 3 mg each day at 9 P.M. The dosing was reduced from the Resident's previous dosing (3 mg twice daily) due to elevated tacrolimus levels noted during his/her hospital stay. Review of Resident #40's Medication Reconciliation, dated 2/27/25, indicated the Resident's list of medications from the facility prior to hospitalization (his/her home medication list) and the Discharge Summary were reviewed and indicated that potential clinically significant medication issues were identified. The document failed to indicate what the discrepancies were or the provider's resolutions for the discrepancies. Review of Resident #40's Physician's Orders indicated on 2/27/25, an order was obtained from the physician via phone for Tacrolimus 1 mg oral capsule - Give 3 capsule [sic] by mouth at bedtime AND Give 2 capsule by mouth one time a day. The order was transcribed on 2/27/25 at 4:03 P.M. Further review of the Physician's Orders indicated the order was subsequently discontinued on 2/27/25 at 6:05 P.M. No tacrolimus was prescribed to the Resident from 2/28/25 until 3/19/25. Review of Resident #40's February 2025 and March 2025 Medication Administration Record indicated the Resident missed 40 doses of tacrolimus that he/she should have received in the facility from 2/27/25 through 3/19/25. Review of Resident #40's Progress Notes indicated but was not limited to: -On 2/27/25, an Order Note entered by nursing indicated an order for Tacrolimus 1 mg - Give 3 capsules by mouth at bedtime and 2 capsules by mouth one time a day was entered and was outside of the recommended dose or frequency (the usually dosing regimen per the note is 3 to 46.5386 capsules two times per day) -On 2/27/25, a progress note was entered by the physician assist (PA). The medication list, included in the PA's progress note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The PA's note failed to identify the change in the Resident's tacrolimus regimen to include the additional 3 mg each day at 9 P.M. -On 2/27/25 at 11:48 P.M., the nurse at the facility documented that the Resident had been treated at the hospital for altered mental status and his/her medications were confirmed by the PA. -On 2/27/25 at 11:56 P.M., the nurse at the facility indicated the Resident's medication list was faxed to the hospital and receipt was confirmed. -On 2/28/25, a progress note was entered by the physician. The physician documented in her note that the Resident was transferred to the hospital on February 22 and returned to the facility on February 27. The physician indicated the Resident was hospitalized due to change in mental status, nausea, and tremors and was treated with antibiotics for a urinary tract infection. The physician indicated the Resident was on immunosuppression with prednisone and tacrolimus and was at high risk of complications and infections. The medication list, included in the physician's note, indicated the Resident was taking tacrolimus 1 mg two capsules in the morning. The physician's note failed to identify the change in the Resident's tacrolimus regimen to include the additional 3 mg each day at 9 P.M. -On 3/8/25, the Resident's medication regimen was reviewed by the pharmacy consultant and no irregularities were noted. -On 3/19/25, a progress note was entered by the physician. The physician's note indicated the nursing notes, vital signs, and medications available in the Resident's electronic health record (EHR), prior external notes, and hospital discharge summary were reviewed. The physician documented that the Resident had received an organ transplant in 2021 and that she was contacted by the hospital's Transplant Coordinator in regard to his/her low tacrolimus level of 1.2 ng/ml. The note indicated the Transplant Coordinator had discussed the Resident's medication regimen with staff at the facility and it appeared that the Resident had missed his/her tacrolimus since he/she was readmitted to the facility on [DATE] and was supposed to receive tacrolimus twice daily. The physician confirmed with nursing staff that the Resident had not received the tacrolimus and was later informed that the Transplant Coordinator had called the facility and recommended the Resident be transferred to the hospital for intravenous steroid treatment. Despite the documentation written in the physician's progress note, the medication list again indicated the Resident was only taking tacrolimus 1 mg two capsules in the morning. -On 3/19/25 at 3:05 P.M., the facility nurse documented that the Resident's cardiologist requested the Resident be transferred to the emergency room at the hospital affiliated with the consulting heart failure team due to the Resident not having immunosuppressant drugs for the last two weeks. The Progress Note indicated the Resident was stable at the time of transfer. Further review of Resident #40's Progress Notes failed to indicate that the physician's order for tacrolimus was discontinued on 2/27/25 or why the medication was discontinued. Review of documentation received from Resident #40's consulting heart failure team indicated, but was not limited to, the following: -At time of discharge from the hospital back to the facility on 2/27/25, the Resident was prescribed tacrolimus 1 mg - Take 2 mg daily at 9 A.M. and take 3 mg daily at 9 P.M. The Resident's tacrolimus level on 2/26/25 was 6.4 ng/ml (goal level was 4-6 ng/ml). A tacrolimus level drawn 2/27/25 remained pending at time of discharge and the facility was to send a tacrolimus level on 3/3/25 to the heart failure team follow-up and dosing recommendations. -On 2/27/25, 3/4/25, 3/5/25, and 3/18/25 the Cardiology Registered Nurse (RN) documented that she called the facility to request the Resident's medication list and lab results be faxed to the cardiology office. The Cardiology RN indicated that she had difficulty reaching a nurse or provider at the facility -On 3/19/25, the Cardiology RN documented that the Resident's labs and medication list were faxed on 3/18/25. The Cardiology RN noted that the labs were drawn on 3/6/25 and the tacrolimus level was 1.2 ng/ml after the dose had been decreased to 2 mg in the A.M. and 3 mg in the P.M. The Cardiology RN reviewed the medication list and no tacrolimus was noted. -On 3/19/25, the Cardiology RN documented that she contacted the Resident's physician at the facility and the physician was unaware of the critical value and discontinuation of tacrolimus and would call back with confirmation. -On 3/19/25 the consulting cardiologist requested to coordinate a hospital admission for the Resident for further testing (transthoracic echocardiogram - a non-invasive test that uses ultrasound to create images of the heart, and possible biopsy - a procedure that involves taking a sample of tissue to examine it more closely). Review of Resident #40's hospital Discharge summary, dated [DATE], indicated, but was not limited to, the following: -The Resident presented to the hospital from the facility with recent history of missed immunosuppression doses and was admitted for rejection surveillance. -The Resident was found to have tacrolimus trough (the lowest level of the drug in the body) of 1.5 ng/ml. TTE and blood work for rejection was reassuring and the heart failure team deferred inpatient heart biopsy. -The Resident was discharged with his/her tacrolimus dosing increased to achieve tacrolimus trough to goal level of 4-6 ng/ml, recommendations for weekly labs including tacrolimus level every Friday for two weeks, prednisone taper for empiric transplant rejection therapy, and changes to his/her insulin regimen due to high blood sugar levels while on prednisone. Review of a Medication Incident and Discrepancy Report Form, dated 3/19/25, indicated that on 2/27/25, Resident #40's tacrolimus had been discontinued in error by a previous employee at the facility. The Form indicated that the Resident's transplant clinic had noted the medication was missing from the Resident's medication list. In the section of the Form titled Outcome of Investigation, it is noted that the medication was not administered and was entered as a one-time administration. During an interview on 5/7/25 at 7:58 A.M., Resident #40 said that he/she had been sent to the hospital at the end of March because he/she had missed doses of his/her anti-rejection medication and the transplant doctor wanted him/her to be monitored. Resident #40 said he/she underwent testing at the hospital and everything was okay and he/she returned to the facility. Resident #40 said he/she did not know how much medication was missed or why. During an interview on 5/7/25 at 12:24 P.M., the Staff Development Coordinator (SDC) said that on 3/19/25, former First Floor Unit Manager #2 approached her and informed her that the hospital had called asking about the Resident's tacrolimus regimen and that he/she was supposed to be on tacrolimus two times daily because he/she had received an organ transplant. The SDC said she was not familiar with the Resident's medication regimen at the time but reviewed his/her record and confirmed that the order for tacrolimus was initially entered but then was discontinued. The SDC said the hospital instructed the facility to monitor the Resident's tacrolimus level and ensure the Resident received his/her medications. The SDC said she did not have further involvement in the situation and that former First Floor Unit Manager #2 handled all further communication with the hospital and the Resident's providers. The SDC said former First Floor Unit Manager #2 was new to the position at the time and no longer worked at the facility. During a telephonic interview on 5/7/25 at 1:01 P.M., the Physician said the Resident's tacrolimus didn't make it onto his/her medication list at the facility. The Physician said the medication was to be used to prevent organ rejection as the Resident had received an organ transplant. The Physician said she was made aware of the omission on 3/19/25 when she was informed by the Cardiology RN at the hospital. During an interview on 5/7/25 at 1:25 P.M., Regional Nurse Consultant #1 said she had been acting as Director of Nursing at the facility from 12/24/24 until the new Director of Nursing started at the facility on 3/14/25. Regional Nurse Consultant #1 said that when a resident is admitted /readmitted to the facility, the nurse entering the resident's physician's orders reviews the hospital discharge records and reviews the medications and then reviews those medications with the resident's provider at the facility. Regional Nurse Consultant #1 said there is a Medication Reconciliation assessment completed in the electronic health record by the nurse after the medications have been reviewed with the provider. Regional Nurse Consultant #1 said the pharmacy also completes a medication review when a resident is admitted /readmitted to the facility. Regional Nurse Consultant #1 said that when a medication error is identified, an incident report is completed and a root cause analysis is done. Regional Nurse Consultant #1 said that in regard to this specific medication error, former First Floor Unit Manager #2 was notified of the error first and then she notified Regional Nurse Consultant #1. Regional Nurse Consultant #1 said she spoke with the Cardiology RN who reported that a medication list had been sent to her and that tacrolimus was not on the Resident's medication list. Regional Nurse Consultant #1 said the Cardiology RN requested to know when the Resident had last received the medication and that his/her tacrolimus level was below goal range. Regional Nurse Consultant #1 said she had reviewed Resident #40's record and identified that the order entered on 2/27/25 was entered as a one-time dose, maybe due to a glitch, and he/she had not received the medication since then. Regional Nurse Consultant #1 said that staff at the facility had not identified the medication error prior to being notified by the Cardiology RN on 3/19/25. Regional Nurse Consultant #1 said that the Cardiology RN notified the facility that the Resident should be transferred to the hospital for admission for rejection surveillance. Regional Nurse Consultant #1 said as a result of the medication error, staff at the facility were reeducated on the process for medication reconciliation and that if there is a medication that they recognize a resident is no longer prescribed, they need to make note of it. During a telephonic interview on 5/7/25 at 1:39 P.M., the Physician Assistant (PA) said he was aware of the medication error and had seen Resident #40 in between his/her readmission to the facility on 2/27/25 and transfer back to the hospital on 3/19/25. The PA said he could not recall when he was made aware of the medication error but if he had been aware of it before the Resident was transferred back to the hospital, he would have restarted the medication at that time. The PA said he did not recall giving an order to discontinue the Resident's tacrolimus on 2/27/25. The PA said he was unaware if the results had been sent to the cardiologist because that is something the nursing staff would do and he did not follow up with nursing to ensure the results were communicated to the Resident's cardiologist. The PA further said he was unaware the Resident had not received the medication at the time the lab value was obtained. The PA said that he was aware the Resident's tacrolimus level had resulted low on 3/11/25, but was not aware the Resident had not received the medication. During an interview on 5/7/25 at 1:59 P.M., the Regional Director of Operations said that when a medication error is discovered, the Director of Nursing at the facility would oversee the investigation, education, follow-up, and any disciplinary action that may occur as a result. The Regional Director of Operations said that when there is no Director of Nursing at the facility, a Regional Nurse Consultant would be assigned to the position until a new Director of Nursing is hired. The Regional Director of Operations said that he was not aware of the medication error before being informed by the survey team on 5/7/25. During a telephonic interview on 5/7/25 at 2:03 P.M., the Cardiology RN said that Resident #40 has been followed by the cardiology team at the hospital since receiving an organ transplant years prior. She said that Resident #40 is seen every three to six months for routine clinic visits and the cardiology team communicates with the facility to obtain an updated medication list periodically, such as when the Resident returns to the facility after a hospitalization. The Cardiology RN said that after Resident #40 was discharged from the hospital on 2/27/25, she reached out to the facility that day to request an updated medication list and labs. The Cardiology RN said she ran into extensive hurdles when trying to contact a nurse or provider at the facility and attempted calls on 3/4/25, 3/5/25, and 3/18/25. The Cardiology RN said she had reviewed the medication list and tacrolimus level on 3/19/25 and noted that the Resident's tacrolimus level was virtually undetectable at 1.2 ng/ml and that the lab had been drawn on 3/6/25 and resulted on 3/11/25, but she had not been notified of the abnormal result prior. The Cardiology RN said she placed a call to the facility on 3/19/25 and spoke with a nurse who reported the medication had been discontinued on 2/27/25. The Cardiology RN said the Resident had gone a significant amount of time without the anti-rejection medication before she was able to speak with someone at the facility. The Cardiology RN said there was no follow-through by the facility staff and she encountered many barriers when trying to get an updated medication list from the facility. The Cardiology RN said the reason a medication list is requested is so the cardiology team can ensure the Resident is taking the anti-rejection medication and that the medication error would have been caught sooner and avoided a hospital admission if the information had been sent to her sooner. The Cardiology RN said that the medication error could have caused organ transplant rejection, which can be irreversible and could have resulted in a severe outcome. The Cardiology RN said that as a result of the medication error, the Resident required a weeklong hospital admission, testing, and intravenous steroid infusions. The surveyor attempted to contact former First Floor Unit Manager #2, but she was unable to be reached and was no longer employed at the facility.