**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to promptly obtain diuretic medication and failed to notify the physician to prevent the continued increase of carbon dioxide for 1 of 2 residents (R24) reviewed for medication errors. This practice resulted in a significant medication error and actual harm when R24 did not receive medication for 4 consecutive days resulting in R24 being sent to the emergency room to receive care for acute onset chronic respiratory failure with hypoxia (condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) and hypercapnia (condition where there is too much carbon dioxide (CO2) in the blood). Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R24's diagnoses included acute on chronic diastolic heart failure, hypertension, hyponatremia, schizophrenia, chronic obstructive pulmonary disease, respiratory failure, acute and chronic respiratory failure with hypoxia, paroxysmal atrial fibrillation, acute kidney failure, dysphagia, and emphysema. R24's physician's order dated 10/25/2024, identified R24 was prescribed 250 milligrams (MG) of oral Diamox (diuretic medication) twice daily for increased CO2 and hypercapnia. Review of R24's laboratory results for labs drawn on 10/25/24, indicated R24's CO2 levels were greater than 45 mmol/L (millimoles per liter). The range for normal CO2 levels are between 20 to 29 mmol/L. Review of R24's medication administration record (MAR) from 10/21/24 to 11/3/24, identified Diamox was ordered on 10/25/24 but was not administered to R24 for a total of eight doses. Seven of the eight doses (10/25/24 through 10/28/24) indicated Not Administered: Drug/Item Unavailable. Dose on 10/29/24 indicated Not Administered: Drug/Item Unavailable - Comment: called A&E for supply. R24's progress notes from 10/25/24 to 10/29/24 gave no indication R24's Diamox prescription was never received from pharmacy or R24's provider was contacted. Progress notes failed to identify any attempt to receive or follow up on R24's Diamox medication. R24's progress note dated 10/29/24 at 11:04 a.m., indicated resident was sent to the emergency department (ER) due to difficulty breathing, severe low oxygen saturations (69%), high respirations (32 breaths per minute) and skin was gray in color. R24's hospital Discharge summary dated [DATE], identified principal diagnoses of acute on chronic respiratory failure with hypoxia and hypercapnia. The following criteria for acute respiratory failure were met; increase of at least 2L (liters) from chronic home O2 (oxygen), PCO2 (partial pressure of arterial carbon dioxide) greater than 50, O2 sats less than 89% more than once, and respiratory rate greater than 20 breaths per minute. Summary indicated shortness of breath, at baseline resident on 3L oxygen and needed up to 15L of oxygen and now back down to 3L, although no wheezing patient had significantly diminished air entry to the bases, was retaining CO2 and likely leading to increased work of breathing and addition of oral prednisone (steroid) for 5 days. R24 was discharged from hospital and returned to facility on 11/1/24 at 1:30 p.m. During interview on 12/4/24 at 10:42 a.m., pharmacist stated Diamox was a lot like Lasix as it helped to rid body of excess fluid and worked by inhibiting the enzymes as it disrupted the balance between acid base ratios. Potential side effects of not receiving the medication would be shortness of breath. Pharmacist stated R24 not receiving eight doses of medication contributed to resident being sent to the ER for increased CO2 and hypercapnia. She would considered this a significant medication error as it would affect her breathing. Pharmacist stated medication was filled on 10/29/24 from the original prescription that was prescribed in April 2024 for once daily. She was not able to find an order, that was prescribed in October, for Diamox twice daily in the system. Pharmacist stated facility may not have sent the updated prescription to the pharmacy. During interview on 12/5/24 at 8:05 a.m., trained medication aide (TMA)-B stated if a medication was not available, she would notify the nurse. TMA-B stated the nurse does the communication/ordering of medications. TMA-B stated she would write down medications that are needed and give them to the nurse as it is sometimes difficult to get things. TMA-B stated if it had been a couple of days and medication was still not available, she notified the nurse again to remind to call pharmacy to see where medication was. During interview on 12/5/24 at 9:01 a.m., nurse practitioner (NP) stated medication was prescribed on 10/25/24 on the direction of Dr. [NAME] for increasing CO2 and hypercapnia based on labs that were obtained on 10/25/24. NP stated she was not aware of facility notifying her of resident not receiving medication. NP stated R24 was sent to the ER due to her history of COPD (chronic obstructive pulmonary disease) and CO2 retention. During interview on 12/5/24 at 10:20 a.m., TMA-C stated if medication was not available, she would first check the Omnicell to see if medication was available and if not, she would report it to the nurse by writing it on her report sheet. TMA-C stated the nurse was the only one that does the communication with pharmacy. TMA-C stated director of nursing (DON) talked to her on 12/3/24 regarding her process if medication was not available. During interview on 12/5/24 at 10:46 a.m., health unit coordinator (HUC)-A and HUC-B stated when a new order was received, they enter the order in the electronic health record (EHR), place the order in file folder for nurse to review and scans the order to their email to send to pharmacy. HUC-A and HUC-B stated they did not have any confirmation page/email that order was sent to pharmacy. During interview on 12/5/24 at 10:58 a.m., licensed practical nurse (LPN)-B stated if a TMA was unable to find a medication, they should go and look in the Omnicell for medication. If medication was not available in the Omnicell, TMA should tell nurse who would call the pharmacy and document the communication in the progress notes. LPN-B stated new orders are entered in the EHR and sent to pharmacy by the HUC and then the nurse would go and verify the order. LPN-B stated she did not remember this medication or if she contacted pharmacy. LPN-B stated if she had contacted pharmacy, she would have documented it in a progress note. LPN-B stated she does not recall being updated by any TMA's that medication was not available. During interview on 12/5/24 at 11:39 a.m., TMA-D stated if medication was not available, she would check the Omnicell and would then notify the nurse. TMA-D stated the nurse was the one that follows up with pharmacy regarding medications. During interview on 12/5/24 at 12:29 p.m., LPN-C stated if medication was not available, Omnicell should be checked for availability. Pharmacy would then be called to check on the status and would also check the medication receipt book from pharmacy to see if medication had been delivered. LPN-C stated a progress note would be documented regarding communication with the pharmacy. During interview on 12/5/24 at 12:39 p.m., DON stated she expected the nurse to contact pharmacy to get clarification on what was happening with delivery of any medication not received. She expected the TMAs to communicate to the nurse on duty when a medication was not available. Some nurses documented pharmacy communication in progress notes, and some documented it on the medication administration record (MAR). DON stated it was best practice to document all communication with providers. New orders were transcribed by the HUC and then placed in the unit folder for the nurse to verify order. DON stated the HUC sent orders to the pharmacy upon transcription of order. DON stated she was on medical leave at the time of medication error and that a preliminary investigation was completed by a LPN-A but was not thoroughly completed. From a clinical standpoint, there was a critical lab value, and we did not give the medication that was prescribed to mitigate the risk. If medication was administered as prescribed, they may not have needed to send R27 to the hospital. During interview on 12/6/24 at 9:19 a.m., LPN care coordinator-A stated if a medication was not available, the TMA would check the Omnicell to see if medication was available and if medication was not in Omnicell, TMA would notify the nurse. LPN-A stated the nurse would call the pharmacy to check on the status of the medication. LPN-A stated she would expect the nurse to document any communication with pharmacy or providers. LPN-A stated she was notified on 10/29/24 that R24 had not received any Diamox that was prescribed on 10/25/24. She followed up with pharmacy, was informed the medication would be out for delivery on the night of 10/29/24. LPN-A stated she started the incident event in the EHR and mentioned the incident to a couple of people but did not do any other investigation and/or interviews regarding incident. During interview on 12/6/24 at 10:00 a.m., DON stated that she was in the middle of investigating the incident when she talked to surveyor on 12/5/24. DON identified if it wasn't charted, it wasn't done and confirmed no documentation was found regarding incident. DON stated education and new procedures were implemented in the past 12 hours to prevent reoccurrence. Changes to procedure consisted of proper communication chains, reminders of what to do when a medication was not available, changed the option in the EMR where TMAs are not able to use the drug unused/unavailable feature and education of placing a progress note on all communications that have transpired. During interview on 12/6/24 at 10:26 a.m., medical director stated the facility had not made him aware of this medication error and found it during his monthly review of incidents and pharmacy review. Medical director stated communication was not timely. The facility Medication Administration policy, dated 10/8/24, indicated medications will be administered by licensed nurses or trained medication aides under the supervision of a licensed nurse. The facility Ordering Medication policy, dated 10/8/24, indicated if medication was not found, staff to look on the printed sheet to verify that it was filled and look for the medication before calling the pharmacy. If, after searching, staff cannot find the medication and it is not in the printout as being sent, call the pharmacy. The facility Trained Medication Aide job description, dated 12/8/2023, indicated TMAs are to report medication refused or not given to the overseeing nurse. The facility Licensed Practical Nurse job description, undated, indicated LPNs coordinated medications, supplies and equipment including ordering, receiving, storing, and disposing of all items in accordance with facility policies and procedures.