**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to ensure physician orders were followed for 2 residents in a final sample of 12 residents and 1 of 27 medications observed during medication administration (Resident identifiers are #20, #3, and #13). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #20 Observation on 10/11/23 at approximately 10:30 a.m. of Resident #20 revealed an approximately 2 by (x) 2 inch white dressing, undated adhered to his/her right cheek. Review on 10/11/23 of Resident #20's current physician's order revealed that there was no order for a dressing to Resident #20's right cheek. Observation on 10/12/23 at approximately 11:15 a.m. of Resident #20 revealed an approximately 2 x 2 inch white dressing, undated adhered to his/her right cheek. Interview on 10/12/23 at approximately 11:15 a.m. with Staff B (Licensed Practical Nurse) confirmed that Resident #20 did not have an order for the bandage. Resident #3 Review on 10/11/23 of Resident #3's October 2023 Medication Administration Record (MAR) revealed the following physician's order: Metoprolol Tartrate Tablet 50 mg [milligrams], Give 1 tablet by mouth two times a day for Hypertension/Heart failure, Hold if SBP [Systolic Blood Pressure] is less than 110 or HR [Heart Rate] less than 55, start date 10/3/23. Further review of Resident #3's October 2023 MAR revealed that on 10/9/23 Resident #3's SBP was documented as 113 and HR was documented as 56. The MAR indicated that on 10/9/23 the Metoprolol was not administered for vital signs outside of they parameter of the physician's order. Interview on 10/12/23 at approximately 10:40 a.m. with Staff E (Director of Nursing) confirmed that the vital signs were not outside of the medication parameters and should have been administered as ordered by the physician. Resident #13 Observation on 10/12/23 at approximately 8:10 a.m. of Resident #13's medication administration with Staff C (Medication Nursing Assistant) revealed that Staff C was going to administer Resident #13 Senna 8.6 mg. Review on 10/12/23 at approximately 8:10 a.m. of Resident #13's October 2023 MARs revealed the following order: Sennosides 8.6 mg - docusate sodium 50 mg tablet, 1 oral, start date 1/5/23. Interview on 10/12/23 at approximately 8:10 a.m. with Staff C confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to provide the necessary care to ensure that a resident's ability to hear was maintained with a communication device for 1 of 1 resident reviewed for communication in a final sample of 12 residents (Resident Identifier is #18). Findings include: Resident #18 Interview on 10/11/23 at 10:00 a.m. with Resident #18 revealed that his/her hearing was poor. Resident #18 was having a difficult time hearing the questions asked therefore an interview was not conducted. Observation on 10/11/23 at 10:02 a.m. revealed that Resident #18 did not have a hearing aid in either ear. Interview on 10/11/23 at 10:05 a.m. with Staff C (Medication Nursing Assistant) revealed that Resident #18 wears a hearing aid and that Resident #18's hearing aid was in. Interview on 10/11/23 at 11:30 a.m. with Resident #18's family member revealed that Resident #18's hearing aids were not always in. Resident #18's family member was not aware of who was responsible for helping Resident #18 with putting them in his/her ears or if Resident #18 would be able to put them in himself/herself. Interview on 10/11/23 at 11:32 a.m. with Staff A (Licensed Practical Nurse) confirmed that Resident #18's hearing aid was not in either ear. Observation on 10/11/23 at 11:35 a.m. revealed Resident #18's hearing aid case on his/her bedside table. Resident #18 was not able to put the hearing aids on himself/herself. Observation further revealed Staff A put the hearing aids in Resident #18's ears. Review on 10/12/23 of Resident #18's care plan, Treatment Administration Record and task section in the electronic medical record revealed no documentation of Resident #18's need for a hearing aid. Observation on 10/12/23 at 9:45 a.m. revealed that Resident #18 did not have a hearing aid in either ear while Resident #18 was sitting in his/her chair, dressed, and eating breakfast. Interview on 10/12/23 at 9:47 a.m. with Staff F (Licensed Nursing Assistant) revealed that Staff F was assigned to Resident #18's care for the day. Interview further revealed that Staff F was not aware that Resident #18 wore a hearing aid. Interview further revealed that Staff F follows the tasks section in the electronic medical record to indicate what Resident #18's care needs would be.

Based on observation, interview, and record review it was determined that the facility failed to ensure that medications were labeled and stored appropriately for 1 of 1 medication carts observed. Findings include: Birch Unit Observation on 10/11/23 at 8:36 a.m. of the Birch Unit medication cart revealed a medication cup with 7 white oval pills that were not labeled in the top drawer. Interview on 10/11/23 at 8:36 a.m. with Staff G ( Licensed Practical Nurse) confirmed the above pills were not labeled. Staff G stated medication was acidophilus and that the pill bottle was in the refrigerator. Review on 10/12/23 of a printed paper provided by the facility on 10/12/23 revealed that three residents receive the above medication on the Birch Unit. Review on 10/12/23 of the facilitys policy titled Medication storage/Storage of Medication dated 01/21 revealed, .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations . 1. Medications are to remain in these containers and stored in a controlled environment .

Based on observation, record review, and interview, the facility failed to ensure that physician orders were accurately transferred from the previous Electronic Health Record (EHR) to the current EHR for 2 out of 27 medications reviewed during medication administration (Resident Identifiers are #9 and #7). Findings include: Resident #9 Review on 10/12/23 of Resident #9's October 2023 Medication Administration Record (MAR), found in the previous EHR revealed the following physician's order for medication administration: Esomeprazole magnesium 20 mg [milligram] capsule delayed release, give 1 capsule by mouth one time a day for GERD [Gastroesophageal Reflux Disease], start date 10/3/23. Review on 10/12/23 of Resident #9's physician's orders in the current EHR revealed the following order: Esomeprazole magnesium 40 mg capsule delayed release, give 1 capsule by mouth one time a day for GERD, start date 5/9/23. Interview on 10/12/23 at approximately 7:20 a.m. with Staff D (Licensed Practical Nurse) confirmed that the correct dosage of the medication did not transfer accurately from the previous EHR to the current EHR. Resident #7 Review on 10/12/23 of Resident #7's October 2023's MAR in the previous EHR revealed the following physician's order for medication administration: Citalopram Hydrobromide tablet 10 mg, give 1 tablet by mouth one time a day for depression, start date 10/5/23. Review on 10/12/23 of Resident #7's physician orders in the current EHR revealed the following order: Citalopram Hydrobromide tablet 20 mg., give 1 tablet by mouth one time a day for depression, start date 4/20/22. Interview on 10/12/23 at approximately 7:40 a.m. with Staff D confirmed that the correct dosage of the medication did not transfer accurately from the previous EHR to the current EHR.