**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to intake #: MI00133943 Based on interview and record review, the facility failed to ensure chemical restraints were not utilized for staff convenience for R117. On 2/7/23 R117 was administered Roxanol (used for the treatment of severe pain) without clinical indication that R117 was experiencing pain and for the purpose of treating R117's behaviors of anxiety, restlessness, and agitation. This deficient practice resulted in an immediate jeopardy beginning on 2/7/23 when R117 arrived to the Emergency Department lethargic, minimally responsive, hypotensive, hypoxic, with bradypenia and pinpoint pupils suspect related to overmedication and places all residents who present with behaviors at high risk to experience serious harm, injury and/or death from use of chemical restraints. Findings: Resident #117 (R117) Review of an admission Record revealed R117 was a [AGE] year-old female, originally admitted to the facility on [DATE], readmitted on [DATE], with pertinent diagnoses which included: dementia, unspecified severity, with other behavioral disturbance, unspecified symptoms and signs involving cognitive functions and awareness, anxiety disorder, autistic disorder, bipolar II disorder, and insomnia. Review of a Minimum Data Set (MDS) assessment for R117, with a reference date of 2/5/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, out of a total possible score of 15, which indicated R117 was severely cognitively impaired. During an interview on 2/28/23 at 10:58 AM, Court Appointed Guardian (CAG) V reported Director of Nursing had approached her multiple times since R117's readmission on [DATE] regarding changing R117's code status to DNR and changing her to comfort care or hospice because of her behaviors only. CAG V reported that R117 had been sent to 4 psychiatric hospitals over the last year and she wanted R117 to remain in the facility because of how disruptive and upsetting being transferred out to different facilities was for R117. CAG V reported she was willing to consent to medication changes to keep R117 stable but became concerned and questioned the rationale of new medications and medication changes when the DON demanded that R117 be made a DNR and begin hospice/comfort care so facility staff could control her behaviors. CAG V questioned why the facility's contracted psychiatrist could not assess R117 and make changes and why the DON was demanding comfort medications for psychiatric diagnoses. CAG V reported there was no rationale provided to her and she became increasingly concerned that the facility staff were going to keep R117 overmedicated and sedated resulting in a poor quality of life. CAG V did not report that R117 had a history of pain requiring the use of opioid analgesic medications. CAG V reported that in the afternoon on 2/7/23 the DON stated that if CAG V did not consent to the use of the roxanol, change R117's Code Status, and allow additional comfort medications then R117 would be sent to the hospital and could not return. CAG V stated that the DON called me and said they had given it (Roxanol) to her (R117) 40 minutes prior and she was still out of control and sent her to the hospital (refer to Nursing Progress Note dated 2/7/23 at 2:05 PM and 2/7/23 at 2:25 PM). CAG V reported that the hospital physician notified her that upon arrival to the Emergency Department R117 was almost comatose and nonresponsive with a dangerously low blood pressure. CAG V reported that the hospital physician felt that her conditional upon arrival was critical. Review of R117's Care Plan revealed no entries related to overall behaviors (interventions to implement when R117 is having increased behaviors, non-pharmacologic interventions for behaviors). Review of R117's Falls Care Plan created 12/10/22 revealed, Resident frequently puts herself on the floor .If (R117) puts self on floor staff to monitor for safety. Indicating R117 had a history of the behavior of placing self on floor. Review of R117's MDS assessment dated [DATE] revealed opioid medications were not administered in Section N-Medications and Pain was not triggered in Section V-Care Area Assessment (CAA) Summary. Review of R117's MDS assessment dated [DATE] revealed opioid medications were not administered in Section N-Medications and Pain was not triggered in Section V-Care Area Assessment (CAA) Summary. Review of R117's Care Plan revealed no entries related to pain and/or pain management (pain medications, non-pharmacologic interventions.) Review of R117's Hospital Records from hospital stay 1/19/23-1/30/23 revealed no documentation of pain. Discomfort noted related to constipation which resolved. Review of R117's Hospital Progress Note for discharge, dated 1/29/23 at 5:15 PM revealed, [AGE] year-old F (female) from (name omitted) Neuropsych unit with past medical history of autism, neurocognitive disorder, Seizure disorder presented with respiratory distress .She has sitter (one on one staff person that remains with resident at all times for safety) .She is stable and plan has been to discharge back to (psychiatric unit name omitted), per (name omitted) neuropsych request, Psychiatrist consulted however now we have been notified that per (name omitted) hospital, patient has finished management there and should go back to her NH (nursing home) in Ml (Michigan) and case manager has started the process .Assessment/Plan .Continue sitter . Confirming that at the time of discharge from the hospital R117 required 1:1 (sitter) staff monitoring. Review of R117's admission Nursing Comprehensive Evaluation dated 1/30/23 at 7:50 PM revealed a pain assessment resulting in 0 of 10 No Pain. Review of R117's Physician readmission note/H&P (History and Physical) dated 1/31/23 at 10:33 AM revealed, (R117) is being seen at (facility) for readmission and for following of chronic conditions. She is post hospitalization for geriatric psychiatric problems. Comorbid conditions include HTN (hypertension), dyslipidemia (high cholesterol), generalized weakness and others. There have not been appetite changes. There have not been any new health care changes .Current emotional concerns includes dementia and bipolar disorder and anxiety . General: She is not in acute distress . Assessment and Plan: (R117) was seen today for follow-up. Diagnoses and all orders for this visit: Dementia with behavioral disturbance (Primary) Bipolar affective disorder, remission status unspecified (HCC) Anxiety Essential hypertension, benign-Dyslipidemia-Generalized weakness-Unsteady gait-Return in about 1 month (around 2/28/2023). Pain was not identified during the comprehensive assessment conducted by Medical Director (MD) F. Review of R117's Nursing Progress Note dated 1/31/23 at 2:05 PM, written by Director of Nursing (DON), revealed, This writer called and spoke to (R117's) Guardian (Court Appointed Guardian (CAG) V). This writer wanted to discuss (R117's) condition and increased behaviors. This writer spoke about possible Hospice/comfort measures for restlessness. (CAG V) was not wanting to discuss comfort measures. (CAG V) stated you are not just going to drug her up to make your job easier .(CAG V) still continued to state you cannot put her on Hospice. I spoke with your Nurse this morning. (CAG V) was again told that (R117's) behaviors have started already, and she was putting herself and others at risk with her aggression. (CAG V) continued to state No. She will not qualify for Hospice .(CAG V) was not wanting to discuss comfort measures stated she would get back with this writer . (Clarification obtained with DON regarding the name of R117's guardian documented in the progress note. DON confirmed R117's guardian as CAG V.) Review of R117's Nursing Progress Note dated 2/1/23 at 1:37 PM, written by DON, revealed, This writer spoke with (Community Mental Health Case Worker (CMHCW W). CMHCW W wants (R117) not to be sent out of facility again. This writer explained to (CMHCW W) that I had spoken to (CAG V) R/T (related to) comfort measures and that (CAG V) was not willing to agree to comfort measures. (CMHCW W) had asked what it would take to keep (R117) at the facility. This writer explained that while (R117) was out to Psych hospital her Guardian would not ok for increased medications as her medications were not working. (R117) was still agitated and restless. When (R117) returned to (facility) she continued to be agitated and restless and the Psych Hospital had decreased her meds R/T her Guardian who insisted She is not to be drugged up. (CMHCW W) stated she would speak with (R117) Guardian and call back. DON did not provide documentation (psychiatric hospital discharge notes, email correspondence with psychiatric facility, legal documentation, etc) prior to survey exit to support the allegation that CAG V refused medication changes at the psychiatric hospital. Review of R117's Hospital Progress Notes from 1/19/23-1/30/23 revealed R117 was sent from the neuropsychiatric unit to the hospital on 1/19/23 for a medical emergency following a seizure. Multiple psychiatric medication changes were made during R117's hospital stay through discharge back to the facility. Psychiatric medication changes during hospital course included: stop clonazepam (antianxiety medication), stop haloperidol (antipsychotic medication), dose decrease for risperdal (antipsychotic medication), and dose decrease for ativan (antianxiety medication). Hospital documentation did not reveal that CAG V refused medication changes. Review of R117's Nursing Progress Note dated 2/1/23 at 1:49 PM, written by DON, revealed, (CMHCW W) from CMH did call back after she had spoken to (R117's) Guardian. (CMHCW W) stated that Guardian was on board with the medication changes. Dr. was notified and new orders received. Ativan 1mg TID (three times a day) and Norco TID. Will monitor for tolerance and effectiveness. Review of R117's Physician Order dated 2/1/23 revealed an order for Hydrocodone-acetaminophen (Norco) 5-325mg 1 tablet three times a day to be administered at 8:00am, 2:00pm, and 8:00pm. Review of R117's Electronic Health Record revealed no documentation of pain from time of admission on [DATE]-[DATE]. Daily pain assessments from 1/31/23-2/2/23 revealed a pain score of 0 out of 10 (no pain). R117's Electronic Health Record revealed no comprehensive assessment indicating R117 was experiencing pain (provocation/palliation, quality/quantity, region/radiation, severity, verbal and nonverbal cues) nor a rationale for beginning a new opioid analgesic to be administered routinely and not as needed for pain. Review of R117's Physician Order dated 2/1/23 revealed an order for lorazepam (Ativan) 1mg tablet three times a day to be administered at 8:00am, 2:00pm, and 8:00pm. Hospital discharge order was for Ativan 0.5mg 2 times a day as needed for anxiety Max Daily Amount: 1 mg. Review of R117's Nursing Progress Notes revealed R117 began to have increased behaviors beginning on 2/5/23. * 2/5/23 at 6:00 AM Resident on the floor on her back 0530. No injuries .Resident was up all night, last dose of Ativan was not given. New schedule for last dose in place. Will continue to monitor. *2/6/23 at 8:07 PM res (resident) one on one most of day. arching back, maneuvering bottom to attempt to slide out of chair . *2/6/23 at 10:20 PM Resident continuously screaming, attempting to get out of bed, throwing her legs over the side, needing to be repositioned every 15 minutes or less . *2/7/23 at 3:20 AM Resident extremely restless throughout the night, needing to be repositioned several times. Staff observed resident nearly on the floor x3 throughout shift from scooting to the very edge of the bed .She appears to need 1:1 assistance to ensure safety. *2/7/23 at 10:35 AM .she was extremely restless, throwing her legs over the side of the bed, rocking back and forth and yelling out. Staff were unable to understand what (R117) was saying. (R117) was assisted into her chair. She then began to scoot towards the front of the chair, trying to scoot self to the floor. (R117 had a known behavior of placing self on floor as evidenced by Fall Care Plan dated 12/10/22). Review of R117's Nursing Progress Note dated 2/7/23 at 10:59 AM, written by DON revealed, This writer along with another Nurse Manger called (R117's) Guardian R/T (related to) her decline/increased behaviors/restlessness, multiple incidents of (R117) putting self on floor. (CAG V), Guardian, was not wanting any medications added at this time .This writer was very clear and stated multiple times to (CAG V) if she did not assist the facility with the proper care for (R117), we would not be able to meet her needs. (CAG V) requested a phone call from Dr. Will continue to monitor. Review of R117's Nursing Progress Note dated 2/7/23 at 11:57 AM, written by DON revealed, .Facility is having difficulties working with Guardian who does not want (R117's) medications increased or changed. Also, left VM for (CAG V), Guardian, to inform of increase of Risperdal in hopes of making (R117) more comfortable as she is still extremely restlessness. (Note: the DON reported CAG V would not allow medication changes despite documenting a new increase in Risperdal). Review of R117's Nursing Progress Note dated 2/7/23 at 2:05 PM, written by DON revealed, This writer spoke with (CMHCW W). (CMHCW W) was informed that (R117) was being sent back out to the hospital as staff could not get her comfortable and Guardian was not willing to work with staff as far as ordering more comfort medications . Review of R117's Nursing Progress Note dated 2/7/23 at 2:25 PM, written by DON revealed, This writer called (CAG V), Guardian, again to discuss the comfort medication Roxinol. (CAG V) did agree to the lowest dose to be given. 0.25ml Roxinol was given with no effect. (CAG V) was informed that (R117) would be sent out to the hospital again for further evaluation. (R117) continued to be a 1:1 and at this time facility could not meet her needs or safety concerns for herself or others .This writer explained that if she, (CAG V), was not willing to change (R117's) code status or allow comfort medications then facility could not meet her needs . At this point (R117) was still a 1:1 and facility could not accommodate that if all were not on the same page. (CAG V) stated yeah I know. You are not going to just give her drugs. This writer again attempted to explain it was not about drugs it was about getting (R117) comfortable. It was explained again that (R117) was extremely agitated and restless. (R117) was continuously screaming open!!!owww!!! (CAG V) continued to Deny comfort medications. (R117) was sent to (name omitted) hospital at this time. (Note: the DON reported CAG V would not allow comfort medications despite documenting CAG V consented to the administration of Roxanol). Review of R117's Controlled Medication Prescription dated 2/7/23 revealed, Roxanol (morphine sulfate) 20mg/ml (milligrams per milliliter) .Directions: 0.25ml (5mg) q2* prn (every 2 hours as needed). There was no clinical indication documented in the order for the use of the Roxanol. Review of the Food and Drug Administration (FDA) prescribing information for morphine sulfate (Roxanol) revealed Morphine sulfate is an opioid agonist indicated for the management of pain not responsive to non-narcotic analgesics. Indicating morphine/roxanol is clinically indicated to manage pain and not for the use of behavior management, restlessness, or agitation. Review of R117's Medication Administration Record revealed Roxanol (morphine sulfate) was administered on 2/7/23 at 12:21 PM for anxiety; restlessness. No pain assessment or documentation was completed at the time of the Roxanol administration confirming the Roxanol was administered to control behavior and not for pain control. Review of R117's Electronic Health Record revealed no documentation of a root cause analysis for R117's increased behaviors: physical assessment, pain assessment, laboratory testing, diagnostic testing, or medication tolerance/effectiveness. During an interview on 3/2/23 at 9:17 AM, Licensed Practical Nurse (LPN) Y reported that she was R117's licensed nurse on 2/7/23. On the day the morphine was administered (2/7/23 at 12:21 PM) R117 had increased behaviors. LPN Y reported that R117 was non-stop moving and attempting to throw herself on the ground. LPN Y reported that R117 had required a 1:1 to keep her in her gerichair. LPN Y reported that R117 had to have a 1:1 at all times and with the number of scheduled staff it was not feasible. LPN Y reported that R117 was not tested for a Urinary Tract Infection (UTI), and they (facility staff) did not feel that was the cause of her increased behaviors. No other testing (labs, xrays, etc) or assessments (pain assessment or comprehensive physical assessment) were completed on 2/7/23. LPN Y reported that the morphine was not effective in controlling R117's restlessness and agitation and R117 was sent to the hospital. Confirming the administration of Roxanol was for staff convenience to control behaviors and due to the insufficient number of staff to provide R117 with a 1:1. During an interview on 3/16/23 at 2:20 PM, Staff Scheduler (SS) I verified that on 2/7/23 there were 2 nurses scheduled and 1 nurse on orientation, 2 CNAs (Certified Nursing Assistants) scheduled on the Memory Care Unit, and 2 CNAs scheduled on the East/West/Central Units. 3 CNAs were scheduled from 6am-6pm and 1 CNA scheduled from 6am-2pm and 1 CNA scheduled 2pm-6pm. R117 resided on the East/West/Central Units. During an interview on 3/2/23 at 3:22 PM, Nursing Home Administrator (NHA) reported that she was familiar with R117 and her condition prior to her transfer to the hospital on 2/7/23. NHA reported that the provider ordered the Roxanol for R117 because she was so agitated. NHA reported there were no additional Progress Notes following the administration of the Roxanol from the provider and the only documentation related to the rationale for the administration of the Roxanol was from the Nursing Progress Notes. During an interview on 3/3/23 at 12:36 PM, Director of Nursing (DON), with survey team present, DON reported that R117 had been a 1:1 because of her increased behaviors prior to her transfer to the hospital on 2/7/23. DON reported R117 had severe psych issues and was uncomfortable and exhibited a lot of agitation and restlessness. She was uncomfortable but don't know if it was psych or physical. DON reported that one day R117 was yelling out oww oww oww (documented x1 on 2/7/23 at 2:25 PM at the time of transfer to hospital). DON could not provide a medical diagnosis confirming a terminal illness and referred to R117's psychiatric distress only. DON reported that admitting R117 to a hospice program would allow R117 to receive more 1:1 care from hospice staff and additional medications could be utilized. When asked why R117 could not have medication changes for psychiatric stabilization and symptom management without being placed on hospice/comfort care, DON did not provide an explanation. When asked if the physician and nurses completed a comprehensive assessment and evaluation to identify the root cause of R117 being uncomfortable both mentally and/or physically DON stated, we missed that. DON reported that R117's behaviors were endangering herself and nurses and had escalated to R117 biting and breaking the skin of a facility nurse. Review of R117's Electronic Health Record revealed the behavior reported by the DON occurred on 12/12/22 (Nursing Progress Note dated 12/12/22 at 8:53 AM) resulting in R117's transfer to the hospital and subsequent transfer to an Indiana psychiatric facility on 12/13/22 (R117 did not return to the facility until 1/30/23) and did not occur between 1/30/23-2/7/23. On 3/16/23 at 12:08 PM, an interview was conducted with NHA, DON, with the survey team and survey manager present. DON reported that Roxanol was not administered as a chemical restraint and was used to get R117 comfortable. DON had previously stated she (R117) was uncomfortable. DON was asked to describe what was meant by the term uncomfortable relating to R117. DON stated, she was just uncomfortable for some reason shape or form. DON was asked why Norco 5/325 mg was ordered and why it was ordered to be administered 3 times a day and not as needed as there had been no documentation that R117 had a history of pain since her original admission to the facility and no clinical indication that R117 was in pain. DON reported that the Norco was started for pain and the scheduling of the medication would be up to MD F and provided no other rationale. DON was asked how it was determined R117 was experiencing pain and the effectiveness of Norco as there were no comprehensive pain assessments documented by the provider or the nursing staff. DON reported that there was documentation that R117 was restless and agitated which could be a non-verbal sign of pain. DON was asked what other non-verbal cues of pain R117 exhibited and stated, the continuous screaming out would be a form of pain and arching back throwing feet over the bed. The DON was asked if R117 displayed non-verbal signs of pain such as grimacing and guarding and did not provide an answer. DON stated, kind of hard to do a full assessment on someone biting punching and kicking you, you could not palpate this woman and reported those behaviors are documented. DON reported that R117 had bit a licensed nurse resulting in a break in her skin. DON was notified that this incident was from prior to her readmission to the facility on 1/30/23 and was verified by NHA. DON was notified at that time that the behaviors she was describing were not documented and attempts to perform a comprehensive assessment were also not documented. DON confirmed that there was no documentation of a comprehensive pain assessment and reevaluation of the use of Norco completed for R117. (Additional behavior documentation was not provided prior to survey exit.) DON stated, basically what you are saying is that there was not a pain assessment done. Reported to DON that the concern was that a resident without a history of pain now displayed symptoms that led DON to believe she was in pain. Norco was started without a rationale from the provider nor a pain assessment, efficacy of the medication was not evaluated, and it was reported by the DON that R117 continued to be in discomfort and yet no root cause analysis was completed: no diagnostic testing, no laboratory testing, and no provider notification and assessment. Then on 2/7/23 Roxanol, used to treat severe pain, was ordered without clinical indication for use, without documentation that R117 was experiencing pain, and administered to control R117's behaviors. DON did not provide a response and remained silent. *R117 required staff to complete incontinence care (brief changes), bathing and transfers with no documentation that R117 refused care or displayed those behaviors while receiving care in her Electronic Health Record nor MDS assessment dated [DATE]. *Only documentation of kicking staff prior to 2/7/23 was on 2/1/23 at 4:04 PM kicking table to move herself back in the wheelchair . *Only documentation of R117 Screaming was on 2/6/23 at 10:20 PM and 2/7/23 at 2:25 PM (at the time of transfer.) *Only documentation of R117 Biting was of her biting down on a spoon during meals on 2/1/23 at 4:04 PM and 2/6/23 at 12:10 PM. There was no documentation that she had attempted to bite staff from 1/30/23-2/7/23. *Review of R117's MDS assessment dated [DATE] revealed: MDS Section E-Behaviors revealed R117 did not exhibit physical behavioral symptoms directed toward others (e,g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and did not exhibit other behavioral symptoms not directed toward others. Verbal behaviors were identified. The MDS reflected that R117's behaviors did not put the resident at significant risk for physical illness or injury, did not significantly interfere with the resident's care and did not put others at significant risk for physical injury. The MDS reflected R117 did not reject evaluation or care which would include: (bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being . The MDS reflected that R117's behaviors had improved compared to prior assessment. *Hospital records dated 2/7/23 revealed R117 was administered Norco in the event that she is in pain and unable to communicate so. Confirming the lack of clinical indication for the use of the opioid. Review of the Emergency Department Provider Note dated 2/7/23 at 2:07 PM revealed, HISTORY OF PRESENT ILLNESS: The patient is a [AGE] year-old female who has a history of bipolar disorder, dementia, and hypertension. She has a legal guardian. History and review of systems is limited secondary to dementia and altered mental status. The history provided was obtained by the guardian (CAG V) and her primary nurse (facility). She has been seen at (facility) intermittently over the last year. In reality, she has been in and out of multiple psychiatric facilities secondary to behavioral disturbances. Her most recent admission was last week. Since returning to (facility), she has had increased behavior disturbances again. She has been flailing around, hitting at staff, screaming out loud, throwing herself on the floor, disturbing other residents. Her Risperdal has been increased, they have also change her lorazepam from as needed to scheduled, they also started Norco in the event that she is in pain and unable to communicate so. Today, they added 5mg Roxanol. They waited approximately 45 minutes prior to transfer. However she continued to have behavioral disturbances and was then sent here. Per EMS, she has been essentially sleeping. Upon arrival, she is minimally responsive. She does open her eyes with painful stimuli or verbal stimuli, however she does not follow commands . Pulmonary: Effort: Bradypnea present. Breath sounds: Decreased breath sounds present . Neurological: Mental Status: She is lethargic and disoriented . Review of R117's admission History and Physical dated 2/7/23 at 6:25 PM revealed, Assessment and plan: The patient is a [AGE] year-old female who has a past medical history of bipolar disorder and dementia. She is well-known for severe behavioral disturbances. She has been in and out of multiple psychiatric facilities over the last year. She has been back at her current assisted living center for the last week. During this time they have noted worsening behavioral disturbances. She has had increases in her medications including her Risperdal dose, her lorazepam was when necessary but is now scheduled, she has also been started on Zyprexa. Today, they added when necessary Roxanol. Prior to arrival, she did receive 5 mg of morphine. Initially, patient was minimally responsive, opening eyes and moving extremities to painful stimuli. She was mildly hypoxic (low oxygen level) in the mid 80s. Pinpoint pupils were present. Suspect this is related to overmedication .Workup today does show an acute urinary tract infection. Rocephin has been ordered. In addition, she has a hypernatremia which is changed since December when she had a hyponatremia. Although this may be related to her dehydrated state, trending the comprehensive metabolic panel will be indicated. Throughout her visit, she has been intermittently hypoxic .She also remains obtunded although improved. I suspect that this is related to polypharmacy and overmedication. However, patient will need to be weaned off of oxygen . Clinical Impressions as of 02/07/23 1724 (5:24 PM) *Altered mental status, unspecified altered mental status type *Dementia with behavioral disturbance *Acute UTI *Hypoxemia *Polypharmacy *Hypernatremia . During an interview on 3/01/23 at 3:18 PM, Hospital Social Worker (HSW) T reported that when R117 arrived at the Emergency Department on 2/7/23 she was lethargic and overly sedated because she had been overmedicated at the facility. HSW T stated that it was reported that R117 was administered morphine for behavioral control and the facility was pursuing hospice care in order to manage her behaviors. HSW T reported that R117 was diagnosed with an acute UTI and Clostridioides difficile (c-diff infection is a severe and sudden infection in the colon) and when those infections were treated R117 returned to her physical and mental baseline. During an interview on 2/24/23 at 8:36 AM, Hospital Unit Manager (HUM) S reported that R117 had increased behaviors while at the facility resulting in the facility increasing medications and adding new medications. HUM S reported that when R117 arrived at the Emergency Department on 2/7/23 she was overmedicated and obtunded. HUM S reported that once she was admitted to the hospital, the physician had to stop her medications and slowly add medications back to ensure R117 was on an appropriate regimen of medication and did not become overmedicated again. HUM S reported that R117 was diagnosed with an acute UTI which was likely the cause of her behavioral issues. HUM S reported that when R117 was admitted to the hospital she was a little squirrely but once her medication regimen was adjusted and her UTI was treated, her behaviors resolved, and she no longer required a 1:1 sitter. (Elderly patients with UTIs often experience behavioral symptoms and confusion). Review of the Drug Interaction Report revealed the concomitant use of Ativan (lorazepam), Norco (hydrocodone/acetaminophen), and Roxanol (morphine sulfate) has the potential to result in profound sedation, respiratory depression, coma, and death. Review of R117's Medication Administration Record (MAR) and Controlled Drug Record (CDR) revealed that on 2/7/23, R117 received the following controlled substances: *Roxanol (morphine) 5mg at 12:20 PM per CDR and MAR *Norco (hydrocodone/acetaminophen) 5/325mg documented as administered at 8:00 AM on MAR and documented as administered at 1:30 PM on CDR. *Ativan 1mg documented as administered at 8:00 AM and 1:30 PM on CDR. Review of R117's Controlled Drug Record for Ativan (lorazepam) 1mg tab 1 tab by mouth three times a day revealed 2 entries on 2/7/23 [TRUNCATED]

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes M100133539, M100131917, and M100135028. Based on interview and record review, the facility failed to acknowledge, identify, and provide adequate supervision to prevent an elopement and ensure the safety of 1 of 7 residents (Resident #111) at risk for wandering, resulting in an Immediate Jeopardy on 11/24/22 at approximately 10:00 PM, when R111 eloped from the facility unbeknownst to staff. R111 was found outside the facility after a citizen call to the police at 10:13 PM. R111 gave her [NAME] name to police who contacted the facility who did not recognize R111 was missing. Police then drove R111 to a gas station approximately 15 miles away. R111 was not discovered missing by facility staff until 12:45 AM (nearly 3 hours later). At 1:35 AM facility staff called the police who knew the last location of R111 and returned R111 to the facility at approximately 2:00 AM. Findings include: Resident #111 (R111) Review of a Face Sheet revealed R111 originally admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbances, unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence. Review of the Minimum Data Set (MDS) dated [DATE] revealed R111 had a Brief Interview for Mental Status (BIMS) indicating she was cognitively intact with no behaviors and independent with cares. Review of the MDS dated [DATE] revealed R111 had a Staff Assessment for Mental Status indicating she was independently and consistently able to make decisions. She rejected care with no other behaviors and independent with cares. In an interview on 2/22/23 at 12:40 PM, Complainant C1 reported R111 has Alzheimer's disease and dementia. Prior to admission to the facility, the resident was found wandering in a field with all her money that she withdrew from the bank in her sock. R111 went to the hospital and the Power of Attorney (POA) was activated in 6/2022. It is unclear if the resident eloped from the facility because the facility did not communicate that with the POA. In an interview on 2/23/23 at 11:04 AM, Licensed Practical Nurse (LPN) D reported R111's moods would go back and forth depending on the time of day and can be loud and short tempered. The day the resident left the facility, she chose to leave and called for transportation herself. In an interview on 2/24/23 at 9:53 AM, Family Member FM1 who is R111s daughter and emergency appointed guardian, that was her original appointed advocate in 2021, reported that the resident had been a Certified Nurses Aide for 40 years in nursing homes and knows a lot. FM1 reported several incidents prior to admission to the facility about the resident unsafely and uncharacteristically wandering in the city and had other behaviors that were not safe and poor decision making. Prior to admission to the facility, R111 had her POA activated in June 2022 at the hospital. R111 signed the Five Wishes in 2021 that made FM1 her patient advocate. R111 is giving the facility a hard time because of her background history of being a CNA for so many years. FM1 reported R111 escaped from the facility in either October or November and heard she went to one of the residential houses and told them to call the police and gave them her [NAME] name. When the police came, they took her to the police station and somehow found her somewhere else in the middle of the night. FM1 reported she received a voicemail sometime during that night that her mother eloped and thinks it may have happened on the night of Thanksgiving. In an interview on 2/24/23 at 11:00PM, the Nursing Home Administrator (NHA) reported R111 did leave the building on 11/24/22 but she did not elope because she was her own person and just wanted to get some potato chips and a pop. So, she called the police to come pick her up. She did not report the incident to the State Agency because it was not an elopement. The resident failed to sign herself out on the Leave of Absence (LOA) book. When asked if there was an incident report for this incident, the NHA provided a summary that was in her soft file in her office. Review of the Summary provided by the NHA regarding R111 leaving the facility revealed R111 was not in the facility on 11/25/22 when staff went into her room around 12:00 AM. The nurse last saw R111 around 11:00 PM (11/24/22) and around 11:30 PM the nurse received a phone call from the police asking if she had a resident with the same first name but a different last name. The nurse told the police they did not have a resident by that name. The police informed the nurse that someone called and said they needed to be picked up in front of the building because they had been thrown out of a vehicle and wanted to make sure this was not their resident. Around 11:45 PM, the nurse locked the front door and saw EMS (emergency medical services) outside and did not think anything about it. The summary concluded R111 did not sign herself out and at an unknown time, the nurse realized the resident was not in her room and searched outside. At approximately 12:45 AM the Director of Nursing (DON) was notified that R111 was not in the building and the police were notified. The police identified the person they picked up in front of the facility was R111 and would be in route to bring her back after she got her coffee and snacks. When R111 arrived at the facility, the NHA educated the resident about signing out on the LOA book and initiated 15-minute checks due to her noncompliance with care and they would know if she left the building without signing out again. No interviews from staff provided, no camera footage available, and no sensical detailed timeline provided. In an interview on 3/1/23 at 9:46 AM, Social Worker (SW) O reported she no longer works at the facility as of 12/28/22. SW O reported R111 would walk around in the parking lot at the facility alone because she was her own person, she did not need supervision and has that right. She would stay outside the building and staff would peek through the windows to check on her. The night of the elopement, R111 wanted some snacks so she called the police to take her to get some snacks. When queried if she knew a resident was walking around at night in the cold and the dark, would you let them? SW O said No, but she was her own person and could go outside because she has that right. In an interview on 3/3/23 at 9:13 AM, the Director of Nursing (DON) was queried about R111 leaving the facility and if she thought that she eloped and the DON replied, I plead the 5th! The DON was read the excerpt in the State Operations Manual (SOM) the definition of an elopement A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. The DON reported she was looking at R111's situation from a capacity view and could understand that by that definition it would be considered an elopement. When queried about a reasonable person's concept for wandering outside alone on a cold dark night, the DON agreed that a reasonable person would not go outside alone at 10:00 PM for chips and a pop. The DON felt that R111 did not spend time with her family on Thanksgiving Day and eat dinner with them which may have triggered her anger and desire to leave the facility. In an interview on 3/9/23 at 4:33 PM, the Fire Chief (FC) P reported he was informed R111 called 911 herself and when they arrived on the scene, he was informed she was kicked out of a car. She was on the ground on the corner not far from the facility (about 100 yards) and had her cane and thinks she had some of her belongings. He called the nursing facility who denied a resident with the last name he gave them that was given by the resident, and then asked the facility if they were missing a resident, and the facility denied missing a resident. His first impression of R111 when he arrived was that she would answer things very well, but none of the information she gave made sense even though it was consistent. It made no sense why she was there. She had no complaints of injury. The police arrived on the scene and was aware they were going to take her to the County Sheriff headquarters. In an interview on 3/9/23 at 5:08 PM, Certified Nursing Assistant (CNA) Q verified she worked the night of 11/24/23 when R111 left the facility. CNA Q reported they were short staffed that night and did not recall seeing R111 near the front doors that night or acting suspicious. CNA Q reported she has never personally seen R111 leave her room. CNA Q thinks R111 got out of the building when another resident came back to facility around 11:00 PM from visiting family. That resident was a 2 person assist back to bed and needed to be changed but that only took about 5 minutes. CNA Q and the nurse that was working that unit were the only ones on that side who assisted the resident to bed and changed him. The other 2 staff were on the memory care unit and the front doors were not locked. CNA Q reported she remembered when they were getting ready to lock the front doors, she saw the EMS outside of the assisted living center next door. CNA Q confirmed R111 got out of the building, and they did not even know it. When they finally realized she was missing, they called the administrator first and then they called the police. When the police brought the resident back to the facility, they put her on 15-minute checks, and she was not happy about it. R111 was on the memory care unit in the past but she did not like being there and would get aggressive, so she went back to the other unit where she is now. R111 would also refuse the wander guard in the past. Since the surveyors have been in the building, she has a wander guard now but does not like it to be checked. CNA Q reported she was told that the resident in the past was in a facility in Muskegon when R111 left and walked an hour away. When queried if R111 answers questions appropriately, CNA Q reported she answers basic questions appropriately. Review of the Police Report with a dispatch date of 11/24/22 at 10:13 PM, arrival time of 10:31 PM, and a clear time of 2:39 AM for a suspicious situation involving R111 revealed: On 11/24/2022 at approximately (10:13 PM), I (Deputy) was dispatched to the intersection of S. Park St./ W. [NAME] St. for a medical complaint. Dispatch advised a woman was thrown from a vehicle and needed assistance. Prior to my arrival, (the Fire Department) arrived on scene and made contact with the woman. (The Fire Department) state, the woman does not appear to have been thrown from a vehicle and is sitting in someone's yard without injuries. The resident reported she was dropped off by her daughter and another male and gave the officer a different last name and date of birth . The officers then took her to a gas station in Ithaca at 11:08 PM per the resident's request. At approximately 1:35 AM, Dispatch received a call from (Nursing Facility) stating one of their patients ran away from the facility. The officer then returned to the gas station in Ithaca and confirmed the resident was the missing person from the facility and brought her back. Review of a map revealed Highway 57 is approximately a half a mile away from the facility. The police officers drove her approximately 15 miles away to a gas station in Ithaca where the resident was there unsupervised for approximately 2 ½ to 3 hours before being transported back to the facility. Review of the weather report for [NAME], Michigan on 11/24/22 revealed a high of 55 degrees and a low of 28 degrees. Review of a Wandering Risk Scale assessment for R111 with an effective date of 7/28/22 and an admission date of 9/8/22 at 3:00 AM revealed she was rated as a High Risk to Wander. Another Wandering Risk Scale assessment with an effective date of 7/28/22 and an admission date of 9/8/22 at 11:49 AM revealed R111 was At Risk to Wander. Review of a Wandering Risk Scale assessment for R111 with an effective date of 8/15/22 and an admission date of 9/8/22 revealed the resident was a High Risk to wander. Review of a Wandering Risk Scale assessment for R111 with an effective date of 9/15/22 and an admission date of 9/8/22 revealed she was a Low Risk for elopement. Section E. History of Wandering was marked as not having a history of wandering, making this assessment inaccurate. Review of an Elopement Evaluation dated 12/14/22 for R111 upon readmission to the facility revealed the resident was ambulatory and had risk factors marked for Resident is cognitive impaired, poor decision-making skills, and/or pertinent diagnosis (Example, dementia, Organic Brain syndrome, Alzheimer's, delusions, hallucinations, anxiety disorder, depression, manic depression, and schizophrenia). The boxes marked for the resident having a history of wandering into unsafe areas and making statements that they are leaving were marked. The Elopement Care Plan not initiated was marked and to see comments - Own responsible person. Review of a Resident Elopement Assessment for R111 dated 2/28/23 revealed the resident is At Risk for an elopement. Review of an email correspondence dated 3/13/23 from the NHA revealed R111 did not have a LOA safety assessment to leave the facility by herself or any education provided to her or her representative. Review of the Care Plan for R111 revealed no indication she was a previous CNA at a Nursing Home Facility or being at risk for wandering/elopements. On 8/3/22 revealed a focus for Behavioral Symptoms due to her diagnoses of Dementia with behavioral disturbances. On 9/1/22 another focus for Behavioral Symptoms due to the resident using psychotropic medications. The care plan overall is not a person focused care plan. On 2/28/23 at 1:00 PM, the Nursing Home Administrator NHA was notified of an Immediate Jeopardy that began on 11/24/22 when Resident #111, who was identified as an elopement risk, eloped from the facility unbeknownst to facility staff. On 3/1/23, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: 1. On 2/28/23 a new elopement assessment was added to the observation task in Matrix by Corporate Social Worker. The DON and Admin were educated on the process of this assessment. Elopement policy was reviewed and deemed appropriate at this time. 2. On 2/28/23, Nurse 1 and 2 were educated by DON on new elopement assessment and scoring system. 3. Beginning on 2/28/23, Nurse 1 and 2 began all elopement assessments for residents to be completed by 3/1/23. 4. Beginning on 2/28/23 all residents will that were determined at risk will have an assessment, anyone at risk for exit seeking or wandering will have a wander guard placed if not on the memory care unit. Residents on the memory care unit do not require wander guards due to it being a secured unit. Care plans updated and revised as appropriate. 5. Beginning on 3/1/23, residents that are their own responsible parties and not at risk for elopement or are approved by responsible parties to go on LOAs will be reviewed to be following policy. 6. Beginning on 2/28/23, re-education will be provided by the regional corporate compliance nurse/Designee to the administrator regarding definition of an elopement. All staff will be re-educated on elopements and residents at risk and how to report concerns. 7. On 3/1/23 Elopement books placed on units for resident identification of elopement risk with face sheet and elopement assessment. The Social worker will be responsible for upkeep. 8. On 2/28/23, Resident #1 (R111) was notified of the concern. 9. On 2/28/23, the Medical Director was informed of the concern and agrees with the plan. Although the immediate jeopardy was removed on 3/1/23, the facility remained out of compliance at a scope of isolated and no harm that is not an Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency, all education had not yet been completed regarding elopements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI000132840 and MI000132219 Based on interview and record review, the facility failed to ensure 1 resident (Resident #114) was free from significant medication errors resulting in an Immediate Jeopardy (IJ) when transcription errors resulted in 1. Multiple dose changes of Clozaril without adequate laboratory monitoring or clinical rational, 2. A transcription error resulted in a dose reduction of a medication used to treat hypotension without adequate blood pressure monitoring and 3. When a transcription error resulted in a dose of Cymbalta that exceeded FDA guidelines without clinical rational. This deficient practice resulted in the high likelihood for R114 to experience over sedation, medication administration without physician knowledge and over-sight and lack of side effect monitoring when administering antipsychotic, antidepressant and cardiac medication and for R114 to experience psychiatric decompensation, newly emerging psychosis, rapid onset of agitation, neutropenia, and decreased efficacy of Clozaril when the medication is titrated again. This deficient practice continues to have a high likelihood to cause serious harm, injury and or death to all residents receiving medications in the facility. Findings: Review of the manufacturer guidelines Clozapine Rems revealed, Clozapine/Clozaril is a prescription medicine to treat people with schizophrenia who have not responded to other medicines. Clozapine may also reduce the risk of suicidal behavior . Clozapine can cause a blood condition (severe neutropenia), which can lead to serious infections and death. Neutropenia occurs when you have too few of a certain type of white blood cells called neutrophils. This makes it harder for your body to fight infections . Getting your blood tested is important because a low number of neutrophils may not cause any symptoms until you have an infection. Having a blood test helps your doctor know if you are more likely to get an infection. You must have regular blood tests before you start taking clozapine and during your treatment. This test is called absolute neutrophil count (ANC). If the number of neutrophils, or ANC, is too low, you may have to stop clozapine. Your doctor will decide if or when it is safe to restart clozapine . The Clozapine REMS will keep track of your blood test results so your doctor and pharmacist know if it is safe to fill your clozapine prescription. Remember: You must get your blood tested before you can receive clozapine from your pharmacy . Midodrine works by constricting (narrowing) the blood vessels and increasing blood pressure. Midodrine is used to treat low blood pressure (hypotension) that causes severe dizziness or a light-headed feeling, like you might pass out. midodrine is for use only when low blood pressure affects daily life. Midodrine may not improve your ability to perform daily activities. (accessed from Midodrine Uses, Side Effects & Warnings - Drugs.com on 3/24/23 at 8:00 AM) Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor antidepressant (SSNRI). Duloxetine affects chemicals in the brain that may be unbalanced in people with depression.Cymbalta is used to treat major depressive disorder in adults. It is also used to treat general anxiety disorder in adults and children who are at least 7 years old. Cymbalta is also used in adults to treat nerve pain caused by diabetes (diabetic neuropathy), or chronic muscle or joint pain (such as low back pain and osteoarthritis pain). Usual Adult Dose for Depression: Initial dose: 20 mg to 30 mg orally 2 times a day Maintenance dose: 60 mg per day, given either once a day OR 30 mg orally 2 times a day Maximum dose: 120 mg/day. Overdose symptoms may include vomiting, dizziness or drowsiness, seizures, fast heartbeats, fainting, or coma. (accessed from Cymbalta Uses, Dosage, Side Effects & Warnings - Drugs.com on 3/24/2023 at 8:00 AM) Review of the Fundamentals of Nursing revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition. Resident #114 (R114) Review of a facility admission Record reflected R114 admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type, idiopathic hypotension, repeated falls, muscle weakness, candidiasis, hereditary motor and sensory neuropathy, intellectual disabilities, hyperlipidemia, restless leg syndrome, open-angle glaucoma, major depressive disorder, encephalopathy, somnolence, cerebral infarction, age related osteoporosis without current pathological fracture, hypothyroidism and anxiety. Review of an OBRA admission Minimum Data Set (MDS) assessment dated [DATE] reflected R114 admitted to the facility from the community (Assisted Living Center) on 7/22/2022. A Brief Interview for Mental Status (BIMS) assessment determined R114 was cognitively intact as evidenced by a score of 13/15. The assessment indicated R114 was independent with bed mobility, transfers and walking; needed set up help only for eating, needed supervision and set up help only for dressing and toilet use and limited assistance from one person for personal hygiene. Review of an OBRA Quarterly MDS assessment dated [DATE] (three months after the admission assessment) reflected R114 was severely cognitively impaired as evidenced by a BIMS score of 7/15. R114 required supervision and one person to physically assist for bed mobility, required extensive assistance from one person for transfers, dressing and toilet use needed one person to physically assist her with walking once or twice in the lookback period. R114 was not steady but able to stabilize with human assistance with moving from a seated to standing position, walking and turning around and facing the opposite direction while walking and when moving on an off the toilet or during surface-to-surface transfers. Review of R114's referral pre-admission Medication Orders from an Assisted Living facility reflected the following pertinent orders: 1. Clozapine 25MG ODT (Oral Disintegrating Tab) Flazco 25 MG ODT Tab Give 3 tablets (=75MG) by mouth in the morning and give 1 tablet by mouth at bedtime. 2. Clozapine 100/ODT Tab Fazaclo 100/ODT Tab Give 2 tablets (=200MG) by mouth at bedtime. The total dose of Clozapine = 300MG/day 3. Duloxetine HCL 30 MG Cap Cymbalta 30 MG cap Give one Capsule by mouth in the morning. 4. Duloxetine HCL 60 MG Cymbalta 60 MG Cap Give 1 capsule by mouth in the morning. The total dose of Duloxetine = 90 MG/day 5. Midodrine HCL 5MG PO Tab Take 1 tablet 3 times daily morning, mid-day & 4 hours before bedtime. The total dose of Midodrine = 15 MG/day Review of R114's Medication Administration Record (MAR) for the month of July 2022 reflected the following orders: Clozaril Tablet 25MG (cloZAPine) Give 3 tablet by mouth one time a day for schizophrenia-Start Date-7-23-2022 0700-D/C Date-08/02/2022 cloZAPine Tablet Disintegrating 25MG Give 1 tablet by mouth at bedtime related to schitzoaffective disorder bipolar type(F25.0) -Start Date-7/28/2022 1900 cloZAPine Tablet Disinegrating 25MG Give 3 tablets by mouth one time a day related to schizoaffective disorder bipolar type (F25.0_-Start Date-07/29/2022 0700 FazaClo Tablet Disinegrating 100MG (cloZAPine) Give 200MG by mouth at bedtime for schizoaffective disorder -Start Date-7/22/2022 1900 -D/C Date-7/28/2022 1623 In summary, from 7/22/2022-7/27/2022 R114 received a total of 275MG of Clozaril. On 7/28/2022 R114 was given 100MG of Clozaril. On 7/29/2022 R114 began receiving 175MG of Clozaril per day. No documentation in the clinical record accounted for the significant dose reduction or increase. No evidence there was an increase in laboratory monitoring was found. Review of R114's MAR for the month of August 2022 reflected the following orders: cloZAPine Tablet Disintegrating 25MG Give 1 tablet by mouth at bedtime related to schizoaffective disorder bipolar type (F25.0)-Start Date-7/28/2022 1900 cloZAPine Tablet Disintegrating 25MG Give 3 tablet by mouth one time a day related to schizoaffective disorder bipolar type (F25.0)-Start Date 7/29/2022 0700 cloZAPine Tablet Disintegrating Give 200MG by mouth at bedtime related to schizoaffective disorder bipolar type (F25.0)-Start Date-08/02/2022 1900-D/C Date-8/11/2022 1808 cloZAPine Tablet Disintegrating Give 25MG by mouth at bedtime for mood related to schizoaffective disorder bipolar type (F25.0)-Start Date-8/11/2022 1900: Clozaril Tablet 25MG (cloZAPine) Give 3 tablet a day for schizophrenia -Start Date-7/23/2022 0700 -D/C Date-8/02/2022 1445 In summary: R114 received 175MG of Clozaril on 8/01/2022 then 375MG of Clozaril on 8/2/2022. R114 was hospitalized from [DATE] until 8/11/2022. On 8/11/2022 R114 was given 50MG of Clozaril. Starting 8/12/2022 R114 was given a total of 125MG of Clozaril per day. No rational for the significant dose reductions and significant dose increases were found in the clinical record. No evidence R114's ANC was monitored more frequently after the significant dose increases were found. Review of R114's September 2022 MAR reflected the following orders: cloZAPine Tablet Disintegrating 25MG Give 1 Tablet by mouth at bedtime related to schizoaffective disorder, bipolar type (F25.0)-Start Date-7/28/2022 cloZAPine Tablet Disintegrating 25MG Give 3 tablet by mouth one time a day related to schizoaffective disorder, bipolar type (F25.0)-Start Date-7/29/2022 0700 cloZAPine Tablet Disintegrating Give 25MG by mouth at bedtime for mood related to schizoaffective disorder, bipolar type (F25.0)-Start Date-8/11/2022 In summary: R114 received a total of 125MG/day of Clozaril for the month of September 2022. Review of R114's October 2022 MAR from PCC reflected the following orders: cloZAPine Tablet Disintegrating 25MG Give one tablet by mouth at bedtime related to schizoaffective disorder bipolar type (F25.0) -Start date- 7/28/2022 1900 cloZAPine Tablet Disintegrating 25MG Give 3 tablet by mouth one time a day related to schizoaffective disorder bipolar type (F25.0)-Start Date- 7/29/2022 0700 cloZAPine Tablet Disintegrating 25MG by mouth at bedtime for mood related to schizoaffective disorder bipolar type (F25.0)-Start Date-8/11/2022 1900 Duloxetine HCl Capsule Delayed Release Sprinkle 30MG Give 1 capsule by mouth one time a day for major depressive disorder-Start Date-8/13/2022 0700 Duloxetine HCl Capsule Delayed Release Sprinkle 60MG Give 60MG by mouth one time a day for major depressive disorder-Start Date-7/23/2022 0700 Midodrine HCl Tablet 5MG Give 1 tablet by mouth 3 times a day for hypotension-Start Date-7/22/2022 1900 In summary: R114 was receiving 125MG/day of cloZAPine, 90MG/day of Duloxetine and 15MG/day of Midodrine. Review of R114's October 2022 MAR from the new electronic health record (EHR) reflected the following orders: clozapine tablet, disintegrating; 25MG; Amount to Administer: 75MG; oral Once a Day Start Date-End Date 10/03/2022-10/21/2022 (DC Date) clozapine tablet, disintegrating; 25MG; Amount to Administer: 3 tablets; oral Once a Day StartDate-EndDate 10/21/2022-Open Ended duloxetine capsule, delayed rlease (DR/EC); 30 mg; Amount to administer: 30 MG oral Once a Day StartDate-EndDate 10/3/2022-10/21/2022 duloxetine capsule, delayed release (DR/EC); 30 MG; Amount to administer: 3 capsules; oral Once a Day StartDate-EndDate 10/21/2022-Open Ended duloxetine capsule, delayed release (DR/EC); 60 MG; Amount to Administer: 60 MG; oral at bedtime StartDate-EndDate 10/03/2022-12/13/2022 midodrine tablet; 5MG; Amount to administer: 5MG; oral Twice a Day StartDate-End Date 10/3/2022-Open Ended In Summary: R114 was being given 75MG of Clozaril a day. No rational in the clinical record was found to describe the significant dose reduction. R114 also began receiving 150MG of duloxetine, a significant dose increase of the antidepressant without clinical rational. Finally, R114 was only given 10MG of the Midodrine beginning in October with the implementation of the new electronic health record. No evidence in the clinical record was found to explain the dose reduction of the blood pressure medication. No evidence was found that facility staff were monitoring R114's blood pressures on a regular basis. Review of a consultant psychology progress note dated 12/13/2022 reflected At this time would recommend D/C (discontinuation) of 60MG QHS (at bedtime) dose of Cymbalta as maximum recommended dosage is 120MG/day. Patient had been doing well on 90MG QD (every day) previously. Review of a Community Mental Health (CMH) Psychiatry note dated 12/14/2022 reflected Patient (R114) with a history of schizophrenia, who was seen by (name of a CMH physician) in the past for medication management, apparently patient psychotropic medications was managed at a rehabilitation facility, staff (CMH staff) has concerns about medication management and brought her to me to help with her psychotropic medications. There is also concern about her physical wellbeing as well, obviously during this quick encounter I cannot corroborate if there is any neglect or physical abuse per se, but the staff have concern about that. From a psychiatric standpoint, the patient is barely oriented x3, she seemed to be pleasant, she denies any auditory hallucination, but she has major cognitive limitations. I do not know what her baseline is, but at the moment she is unable to manipulate information, her fund of knowledge is poor, but she says she feels okay, noticeable upper extremity tremor, patient uses a walker to help her with her gait, her left arm has limited movement. I got most of the information from the chart and the staff, since the patient has major cognitive limitation. Patient with a history of treatment resistant schizophrenia, apparently dosing of medications has been changed during her admission to rehabilitation. I recommend the dosing of medications that worked for her in the first place, as stated above, as of now I am not sure where patient is to get psychiatric treatment, I recommend she continue with us here to manage her psychotropic medications, on any occasion the dose of Cymbalta at 150 mg as being given to he is above the FDA (Food and Drug Administration) guidelines, and thus has to be reduced to 90 mg which was a dose that she was taking previously, Clozaril has to be titrated up to the dose that she was taking previously, see medication list. During a telephone interview on 3/10/2023 at 9:41 AM, the Consultant Pharmacist reported that he would come to the facility for monthly reviews of resident medication regimens. The Pharmacist reported that he did not notice any issues with the Clozaril and would not pay close attention to that as it is required the prescribing physician and pharmacy must be registered in the Clozapine/REMS program. Review of documentation related to the medication transcription errors reflected the following conclusions as indicated by notes made by the Nursing Home Administrator as follows: The explanation for the Midodrine dose change from 15MG/day to 10MG/day was Matrix (EHR) change over was put in wrong by nurse order should have read 3 times a day. Clozapine was put in Matrix incorrectly by nurse order should have read 75MG AM and 25MG HS (hour of sleep) Discontinue original order at NOC (night) d/t (due to) day med (duloxetine) being at 90MG did not need NOC med at 60MG too. Review of Monitoring History required for the Clozapine/REMS program for R114 reflected that R114 did not have increased laboratory monitoring after significant dose increases. The record revealed an ANC (Absolute Neutrophil Count) was calculated and reported on 7/07/22, 8/04/22, 8/21/22, 9/29/22. An ANC was not reported in October or November 2022. The record reflected that R114 refused to have labs drawn in December 2022 with the records indicating Not reported(Patient Refused). On 3/14/2023 the Administrator was verbally notified and received written notification of the Immediate Jeopardy that was identified on 3/14/23 due to the facility's failure to ensure medications were transcribed and administered appropriately and following FDA dispensing regulations for Clozaril. A written plan for removal for the immediate jeopardy was received on 3/14/23 and the following was verified on 3/16/23: 1. All residents are at risk with this concern (transcription errors). 2. On 3/14/23 all residents on Clozaril were reviewed to ensure all labs were in place and monitored at appropriate frequency. 3. On 3/14/23 all residents on Clozaril were reviewed to ensure orders were correct. 4. On 3/14/2023 all residents on Clozaril were reviewed to ensure all orders matched the MAR. 5. On 3/14/2023 all residents on Clozaril were reviewed for any adverse effects if concerns with medications were found. 6. On 3/14/2023 all residents on Cymbalta were reviewed to ensure current monitoring orders were correct. 7. On 3/14/23 all residents on Cymbalta were reviewed to ensure orders were correct 8. On 3/14/23 all residents on Cymbalta were reviewed to ensure orders matched the MAR 9. On 3/14/23 all residents on Cymbalta were reviewed for any adverse effects if concerns with medications were found. 10. On 3/14/23 all residents on Midodrine were reviewed to ensure all blood pressure checks were in place. 11. On 3/14/23 all residents on Midodrine were reviewed to ensure orders were correct. 12. On 3/14/23 all residents on Midodrine were reviewed to ensure all orders matched the MAR 13. On 3/14/23 all residents on Midodrine were reviewed for any adverse effects if concerns with medications were found. 14. On 3/14/23 all resident orders were reviewed to ensure they matched the MAR. 15. Beginning 3/14/23 all residents that are requiring labs were reviewed to ensure labs were ordered as appropriate. 16. Beginning 3/14/23 all residents with orders were reviewed to ensure appropriate parameters/monitoring are in place for medications ordered. 17. Beginning 3/14/23 licensed nurses were educated on proper medication administration, review of narcotic dispensing, lab ordering, blood pressure monitoring, proper processing of new medication orders and the 5 rights of medication administration. 18. On 3/14/23 the Medical Director was notified of deficient practice and in agreement with plan. 19. On 3/14/23 an Ad-Hoc QA (Quality Assurance) meeting was held with the NHA (Nursing Home Administrator), DON (Director of Nursing), medical director and nurse consultant to review action steps and results to ensure compliance. Although the Immediate Jeopardy was removed on 3/14/2023, the facility remained out of compliance at a scope of pattern and severity of likelihood for harm due to the fact that not all facility staff have received education and sustained compliance has not been verified by the state agency.