**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff, Physician, and resident interviews the facility failed to prevent a significant medication error when Nurse #1 administered Resident #63 medications prescribed to Resident #340 to include carvedilol (a medication classified as a beta blocker used to lower the heart rate and high blood pressure) 25 milligram (mg), losartan (a medication to treat high blood pressure) 25 mg, hydralazine (a medication to treat high blood pressure) 100 mg, and apixaban (a medication to thin the blood) 5 mg on 01/14/24. Resident #63 had previously received her own prescribed carvedilol 25 mg and losartan 100 mg that morning prior to receiving Resident #340's medication which resulted in duplicate medication. Resident #63 was transported by Emergency Medical Services to the hospital emergency department (ED) where she required intravenous (IV) (directly into the vein) administration of norepinephrine (a medication used to treat life threatening hypotension) to increase her blood pressure, 2 liters of IV fluids, and was admitted to critical care management for treatment to prevent life-threatening conditions of shock and toxidrome (a syndrome caused by dangerous levels for toxins in the body, often the consequence of a drug overdose). This deficient practice affected 1 of 5 residents reviewed for significant medication errors. Findings included: Resident #63 was admitted to the facility on [DATE] with a diagnosis that included hypertension, heart failure, cirrhosis of the liver, and renal failure. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was cognitively intact and received an antiplatelet (medication to prevent blood cells called platelets from clumping together to form a clot). Review of the January 2024 physician orders for Resident #63 revealed orders for carvedilol 25 mg and losartan 100 mg. Resident #63 had no orders for hydralazine 100 mg or apixaban 5 mg. Review of the January 2024 Medication Administration Record (MAR) revealed that on 01/14/24 at 8:00 am Resident #63 received all her scheduled medications as ordered to include, carvedilol 25 mg and losartan 100 mg, as evidenced by nursing initials for Nurse #1 and a checkmark on the MAR. Resident #340 was admitted to the facility on [DATE]. Resident #340's physician orders included carvedilol 25 milligram (mg), losartan 25 mg, hydralazine 100 mg, and apixaban 5 mg. In a record review of a medication error incident report completed by the Assistant Director of Nursing (ADON) dated 01/14/24 at 10:45 am it was revealed that a medication error had occurred for Resident #63 when the medication nurse (Nurse #1) scanned medication for administration prescribed to Resident # 340 (who had the same first name as Resident #63) and instead administered the medication to Resident #63. The review further revealed that the medication nurse (Nurse #1) identified Resident #63 by her first name only. Resident #63 received medications not prescribed to her that included: losartan 25 mg, carvedilol 25 mg, and apixaban 5 mg. A record review of a Facility Witness Statement dated 01/14/24 written by Nurse #1 revealed that Nurse #1 administered medication intended for another resident to Resident #63. It further revealed that she entered Resident #63's room and called her by her first name, and Resident #63 answered. Nurse #1 then administered the medication [intended for Resident #340] to Resident #63. As she was exiting Resident #1's room she realized she administered the medication to the wrong resident. The review further revealed that Nurse #1 immediately notified the DON who informed her to notify the Physician and she then paged Physician #2 and he responded and informed Nurse #1 to send Resident #63 to the hospital. She indicated she called EMS and then assessed the resident until EMS arrived. She then notified the family of the medication error, and that Resident #1 was sent to the hospital for monitoring. The completion of this document was signed as witnessed by the DON and the Assistant Director of Nursing (ADON). Review of a nursing progress note written by Nurse #1 dated 01/14/24 at 3:36 pm revealed Resident #63 received her medications 8:00 am. She remained in bed and stated she was feeling better. At 11:00 am, Nurse #1 scanned and prepared another resident's [Resident # 640] medications, walked into Resident #63's room and identified her by first name. Resident #63 received duplicates of carvedilol and losartan as well as a single dose of apixaban. On exiting the room Nurse #1 became aware of the mistake. She checked Resident #63's B/P with results of 159/86 (increased blood pressure) and rechecked 30 min. later with results of 110/68 (decreased blood pressure). Notified the on-call Physician #2. Orders were received from Physician #2 to send Resident #63 to the emergency department. The family member was notified. EMS arrived and transported Resident #63 to the hospital on [DATE] at 12:15 pm. Review of a nursing progress note written by Nurse #1 dated 01/14/24 at 4:02 pm revealed that this note was an addition to Nurse #1's note dated 1/14/24 at 3:36 pm. The documentation indicated that Resident #63 remained alert and oriented, awake and answering questions appropriately. Respirations remained unlabored, at a rate of 16 when emergency medical services arrived. Resident #63's skin was documented as warm, dry, and pale. She denied pain and stated, I'm just really tired. Resident #63 sat up and moved to the gurney with the assistance of the emergency medical technician. An NA remained with Resident #63 until she was transported. In a phone interview with Nurse #1 on 02/08/24 at 11:24 am it was revealed that she was the weekend supervisor on 01/14/24 and had been assigned to Resident #63's unit that day after another nurse did not show up for her shift. She further stated that she was not typically assigned to a medication cart and was unfamiliar with the resident and unit. Nurse #1 stated she had given Resident #63 her prescribed medications around 8:00 am on 01/14/24. She further stated that around noon on 1/14/24 she prepared medications prescribed for Resident #340, who had the same first name as Resident #63. Resident #340 resided in the room next to Resident #63. Nurse #1 stated she entered Resident #63's room with the medications she had prepared for Resident #340 in error. She stated she only looked at the first name on the room door name plate and called Resident #63 by her first name and that Resident #63 responded yes. She further added that she did not verify Resident #63's last name or date of birth and did not compare the picture on the MAR like she should have. Nurse #1 indicated that she then gave the medication that she had prepared for Resident #340 to Resident #63 and by the time she got back to the medication cart she realized that she had given the wrong medication to Resident #63. She stated that she immediately called the DON and then called Physician #2 and was instructed to send Resident #63 to the hospital for further evaluation and monitoring. The interview further revealed Nurse #1 had checked Resident #63's blood pressure right after she realized she gave Resident #63 the wrong medications and re-checked her blood pressure again 20 minutes later and she noted that Resident #63's blood pressure was lower the second time. She stated she called Emergency Medical Services (EMS) and the resident was sent to the hospital for further evaluation and monitoring. She then notified the family. Nurse #1 stated that she was stressed on 01/14/24 because she wasn't familiar with that unit. She further added that the call bell system was not working, and residents were given handbells to call for assistance and she was trying to assist in answering the handbell calls. She added she was behind on administering medications and other residents had come to the medication cart and asked for their medication. She further added that family members of other residents came to her to ask questions, and this caused her to be rushed and she just didn't verify the identity of Resident #63 like she should have. Review of progress note written by Physician #2, the Medical Director, on 01/14/24 at 12:04 pm revealed that he was contacted by a nurse that a resident had a medication error and was given another resident's medications. The note further revealed that Resident #63 had received her own carvedilol 25 mg and losartan 100 mg and in addition received another carvedilol 25 mg, another losartan 100 mg, and received hydralazine 100 mg. In addition, she is quite anemic with a hemoglobin of 7.5 and she received apixaban. The review indicated that Resident #63 could not be monitored safely in the facility and should be monitored on telemetry (continuous heart monitoring), so she was sent to the hospital to be closely monitored. Review of the EMS report dated 01/14/24 revealed EMS responded to a call to the facility because staff gave Resident #63 someone else's medication. The primary impression on the report was documented as poisoning/drug ingestion. Blood pressures monitored during EMS transport to the hospital emergency department indicated blood pressures of, at 12:22 pm 130/54; at 12:34 pm 103/57; at 12:40 pm 108/60; at 12:46 108/63; and at 12:51 95/50. An IV catheter was inserted at 12:48 pm and a saline lock (a short section of tubing attached to the end of an IV catheter that is filled with normal saline solution and then capped to close off the tubing until medications are ready to be administered). The record review further revealed that staff reported to EMS that they had given Resident #63 her prescribed medication and 30 minutes later gave her someone else's medication. It was reported to EMS that Resident #63 was given an extra 25 mg of carvedilol, and extra 100 mg of losartan and was given 2 other medications, that included, apixaban 5 mg and hydralazine 100 mg, not prescribed to her. EMS personnel assessed and monitored the resident continuously while enroute to the hospital. Review of hospital ED records dated 1/14/24 revealed Resident #63 was received in the ED on 01/14/24 from EMS for a chief complaint of hypotension. The original ED assessment and plan outlined and included the following (as written): 1. Unintentional drug administration 2. Hypotension a. Patient normally takes Coreg 25 mg and losartan 100 mg. b. Given additional doses of coreg [carvedilol] 25, losartan 100, hydralazine 100, and Eliquis [apibaxan] 5 by mistake at her facility. c. Monitor vitals. d. Given a 2-liter bolus [IV fluid administered at a rapid rate to improve cardiac output, correct low blood pressure and ensure sufficient renal blood flow] in ER and will continue IV fluid hydration. e. Start peripheral levophed [norepinephrine] and keep MAP [mean arterial pressure] greater than 65 and decrease if able. 3. Hypertension a. Hold home meds. The hospital record review further revealed that Resident #63's blood pressure was 102/67 when she arrived in the hospital emergency department at 12:55 pm and entered triage at 1:04 pm. She was oriented to person, place, and time, was at high risk of morbidity, and had high complexity. She was placed in observation. At 1:10 pm Resident #63's blood pressure was trending downward, and her MAP was <65, a bolus of intravenous fluids was hung to be administered. Vital signs were monitored every 10 minutes and blood chemistry studies were done. An electrocardiogram (EKG) (a test to detect heart problems) was done and revealed a prolonged QT [an irregular heart rhythm] wave abnormality. Poison control was consulted for recommendation in the care of Resident #63 because of the overdose of medication. Poison Control recommended norepinephrine already explained in the PS and to repeat an EKG to ensure the QT prolongation had resolved. At 3:54 pm her blood pressure dropped into 80s/40s, and the physician ordered Resident #63 to be admitted to the hospital to critical care. Resident #63 was discharged from the ED observation at 3:58 pm and admitted to the hospital in critical care, she continued to receive intravenous norepinephrine to treat low blood pressure. A Physician progress note dated 01/14/24 at 3:59 pm indicated that critical care was necessary to treat or prevent imminent or life-threatening deterioration for the following conditions: shock and toxidrome and that critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. At 5:36 pm Resident #63's blood pressure was 117/87 and her MAP was 96. Her blood pressure was monitored every 10 minutes. The medication error that resulted in the hospitalization of Resident #63 was resolved 48 hours after admission. Resident #63 was hospitalized for a total 4 days, the later portion to of the hospitalization was related to additional gastrointestinal issues that arose after being admitted to the hospital, that was later determined to not be related to the medication error. Resident #63 was discharged from the hospital on [DATE] to home with home health. In a phone interview with Resident #63 on 02/09/24 at 9:28 am she stated that she could recall that on 01/14/24 nurses (could not recall names) kept going in her room at the facility and asked how she felt. I told them I was tired and sleepy because I didn't not get much sleep the night before. She further stated that initially she did not know why staff kept asking her how she felt and then a nurse that she had never seen before told me she had given me my medication and another patient's blood pressure medication and blood thinner, and the doctor had recommended that I be sent to the hospital. She stated that one nurse came in and stayed with her until the rescue squad arrived indicating that she was not left alone during this timeframe. Resident #63 further indicated that she was feeling very sleepy and when the rescue squad arrived, she was taken to the hospital. She stated when she arrived at the hospital she was really scared, and her stomach started hurting and she got sick to her stomach. She stated her blood pressure then bottomed out and they went to working on me trying to get my blood pressure back up. She described the stomach pain that she had as a 9 on a 0/10 scale used to measure intensity of pain (0 being no pain and 10 being the worst pain). Resident #63 stated she was in the emergency department all night and then was admitted to the hospital. She stated the doctor told her that her stomach pain occurred because her blood pressure bottomed out. She further added that she was in the intensive care step down unit and had monitors on her that checked her heart, she received fluids and medications intravenously through an IV, and they had to call poison control. Resident #63 stated that when the nurse at the facility brought her Resident #340's medications that she didn't question it because they always brought her medication throughout the day, and she trusted that it was her medication. She stated that they usually asked her for her full name and birthdate but didn't think Nurse #1 asked her that day and just said my first name. In a phone interview with Physician #2 (the Medical Director) on 02/06/24 at 12:15 pm it was revealed that Nurse #1 notified him by phone of a medication error in which she administered another resident's medication to Resident #63. She told him that she had already administered Resident #63 her own prescribed medications on the morning of 1/14/24. Physician #2 recalled that she had given Resident #63 blood pressure reducing medications and a blood thinner not prescribed to her. He further added that she received her own prescribed carvedilol and losartan and then received duplicate doses of carvedilol (beta blocker) and losartan, as well as apixaban (a blood thinner). Physician #2 stated that when Nurse #1 called him Resident #63's vital signs were not concerning to him at that time, but he anticipated what the outcome could be, and he felt that she would need monitoring at the hospital because of the medication error so he called the hospital emergency department himself to give them report on Resident #63. He added he was concerned that she could go into heart block and her pulse rate would decrease down into the 30's and her blood pressure could decrease, and she would become unconscious and all of the medications that she received would cause her blood pressure to decrease. He stated if the blood pressure became too low that it could cause kidney function problems. He further stated that she had cirrhosis of the liver and that caused concerns of bleeding because of the blood thinner. He stated it could take a few days for the beta blocker to clear her system. He stated the resident was at risk for harm and required monitoring, stating if her blood pressure became too low that she would require care in the Intensive Care Unit at the hospital. Physician #2 stated that he felt the situation was handled appropriately by the facility and he was contacted immediately. In a review of an Investigational Summary completed by the facility dated 01/14/24 addressed to the Quality Assurance Committee revealed that a Medication Error occurred on 01/14/24 and that a dayshift nurse had administered the wrong medication to Resident #63 in error. Resident #63 was sent to the emergency department for monitoring related to Resident #63 received increased dosage of blood pressure medication and a blood thinner. The investigational summary revealed there were 3 residents with the same first name on the same unit and the nurse entered Resident #63's room and called the resident by her first name. She then gave Resident #63 the wrong medication. In an interview with the Director of Nursing (DON) on 02/8/24 at 11:05 am it was revealed that she was aware of a medication error that occurred on 01/14/24 by Nurse #1. The DON stated that Nurse #1 called her right away on 01/14/24 to report that she had made a medication error and gave Resident #340's medication to Resident #63 in error and that Resident #63 had already received her own prescribed medication, which caused her to receive duplicate blood pressure medication. The DON further added that the medication error could cause Resident #63 to become hypotensive and could have caused cardiac issues in a resident with a cardiac diagnosis. She stated the resident was sent to hospital for routine monitoring. She stated that Nurse #1 was a supervisor and was not usually assigned to a medication cart. Another nurse had called out on 01/14/24 and Nurse #1 was assigned to the medication cart. The DON stated that Nurse #1 should have verified the resident using full name first and last, picture on the electronic medication administration record (e-MAR) and if she was still unsure, she should have asked someone that was familiar with the resident. The interview further revealed that the normal protocol for medication training for nurses was that they received medication administration training for 3 days with another nurse before they are assigned to a medication cart, and if they are not comfortable the training is extended until they are comfortable. They learn to use e-MAR and how to scan meds. Nurses also received computer-based on-line training that included the five rights of medication administration and how to identify a resident. To identify a resident the nurse should compare the picture on the e-MAR to the resident, knock on door and ask the resident their full name. If the resident is not alert and oriented and cannot tell you who they are then the nurse should compare the picture on the e-MAR to the resident and ask a staff member that is familiar with that resident. The DON stated that Nurse #1 received the required medication administration training. Nurse #1 was re-educated but was not disciplined because she resigned from her position right away. Review of medication administration training transcript for Nurse #1 revealed that she had completed computer-based learning modules titled Medication Administration Safety on 08/30/23 and Medication Scanning on 01/10/24. In an interview with the Administrator on 02/06/24 at 12:37 pm it was revealed that she was aware of the medication error regarding Resident #63 and that the nurse immediately notified the DON and the Medical Director, and they decided that due to the type of monitoring required that the resident would be sent to the hospital for further evaluation and treatment. She stated she felt that the medication error occurred because the nurse had distractions of a family member repeatedly coming to the med cart to ask questions and Nurse #1 got distracted and should have just put her medication cart up for the time being. This was the first time this nurse had made any medication errors. The interview further revealed Nurse #1 was very upset that it had occurred and told her that she had other residents with the same first name as Resident #63 and she gave Resident #340's medication to Resident #63 because they had the same first name. She stated after the error occurred the facility did a 100 percent audit for all residents with like names and assessed other resident to make sure they got their meds accordingly, she stated they did some medication pass audits with nurses. The interview further revealed that a Performance Improvement Plan was done and the plan was still in progress. The Administrator stated Nurse #1 should have done the 6 rights of medication administration to include asking the resident her name, first and last name and verifying it with the e-MAR and the picture on e-MAR. The Administrator was notified of Immediate Jeopardy on 02/06/24 at 3:10 pm. The Administrator provided the following corrective action plan with a compliance date of 01/18/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice On 01/14/24, Nurse #1 prepared Resident #340's medication at the medication cart. She entered the room of Resident #63, who has the same first name as Resident #340. She called the resident's first name, and the resident responded. The nurse then administered Resident #340's medications to Resident #63 in error. While exiting the room, the nurse realized she had given the resident the wrong medication. The nurse immediately assessed the resident and obtained vital signs. Blood pressure 159/78, heart rate 77, respiratory rate, 16-18, the resident remained alert and oriented, and able to answer all questions appropriately. The nurse notified the Director of Nursing (DON) and the physician of the medication error, and the resident was sent to the emergency room for monitoring per the physician's recommendations. The resident was admitted to the hospital for monitoring of medications administered in error and was treated with medication for low blood pressure, which was resolved within 24 hours. On 01/16/24, a root cause analysis was completed by the Administrator and Director of Nursing. The root cause of the medication error was determined to be Nurse #1 administered medication to Resident #63 without appropriately confirming the resident's complete name and utilizing the resident's picture in the electronic medical record as an identifier. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 01/16/2024, the Assistant Director of Nursing (ADON) and Unit Manager initiated an audit of all residents for signs and symptoms of acute changes in condition to investigate the cause of the change and ensure the change was not related to significant medication errors. There were no areas of concern identified during the audit. The audit was completed by 01/17/2024. On 01/16/2024, an audit of all progress notes for the past 14 days was initiated by the DON. This audit was to identify any documentation related to a resident with an acute change from a significant medication error to ensure the resident was assessed, interventions were initiated, and the physician was notified for further recommendations. There were no areas of concern identified during the audit. The audit was completed by 01/17/2024. On 01/17/2024, the ADON and Unit Manager initiated Medication Pass Audits with all nurses and medication aides including agency. This audit was to ensure (1) the nurses and/or medication aides administer medications per the physician's order (2) staff utilize the rights of medication administration to include the right medication and to the right resident by asking the resident their full name and using the picture in the electronic medication administration record as an identifier and (3) staff demonstrated what to do if resident, family or staff interrupt during medication administration to avoid errors. This includes restarting the 6 rights of medication administration prior to administering the medication to a resident. The ADON and Unit Manager addressed all concerns identified during the audit including reeducation of staff if indicated. There were no other significant medication errors identified during the audit. The audit was completed by 01/17/2024. After 01/17/2024, any nurse or medication aide including agency who has not worked or completed the medication pass audit completed it upon the next scheduled work shift. On 01/16/2024, the ADON initiated an audit of all residents with like names and proximity of room locations. Name alerts were placed on the medication administration record (MAR) for residents with similar names and rooms within close proximity of each other. The ADON addressed all concerns identified during the audit, including posting name alerts in the medical record. The audit was completed by 01/17/2024. On 01/16/2024, the DON completed an audit of all incident reports for the past 30 days to identify any medication administration concerns resulting in medication errors. No additional concerns were identified during the audit. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 01/14/2024, ADON initiated an in-service with all nurses and medication aides to include agency regarding the?Rights of Medication Administration. The education emphasized (1) administering medications per physician order, (2) the rights of medication administration including but not limited to the right medication to the right resident, and (3) disposing of medications if not administered immediately (4) how to identify residents with emphasis on asking resident to state full name and utilizing electronic record photo to verify residents prior to administering medications (5) what to do if you are still not sure of the resident's identity i.e. ask a staff member familiar with the resident to verify their identity and (6) what to do if residents, family or staff interrupt during medication administration to avoid errors which includes restarting the 6 rights of medication administration prior to administering the medication to a resident. The in-service was completed by 01/17/2024. After 01/17/2024, any nurse or medication aide including agency who had not worked or completed the education completed it prior to the next scheduled shift.? All newly hired nurses and medication aides including agency will be educated by the Director of Nursing or Nurse Supervisor during orientation, prior to performing medication administration, regarding the?Rights of Medication Administration including (1) administering medications per physician order, (2) the rights of medication administration including but not limited to the right medication to the right resident, and (3) disposing of medications if not administered immediately (4) how to identify residents with emphasis on asking resident to state full name and utilizing electronic record photo to verify residents prior to administering medications (5) what to do if you are still not sure of the resident's identity i.e. ask a staff member familiar with the resident to verify their identity and (6) what to do if residents, family or staff interrupt during medication administration to avoid errors which includes restarting the 6 rights of medication administration prior to administering the medication to a resident. The Administrator will track to ensure the education is completed by utilizing the staff new hire and/or agency orientation checklist. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The decision to monitor the system for prevention of significant medication errors was made on 1/16/24 by the Administrator and Director of Nursing and presented to the Quality Assurance Committee on 1/16/24. The ADON and Unit Manager will complete 5?Medication Pass Audits?across all shifts with nurses and medication aides weekly x 6 weeks then monthly x 2 months. This audit is to ensure (1) the nurses and/or medication aides administers medications per the physician's order (2) staff utilizes the rights of medication administration to include the right medication and to the right resident (3) the staff utilizes the appropriate technique when identifying residents and (4) staff demonstrates what to do if resident, family or staff interrupt during medication administration to avoid errors. The ADON and Unit Manager will address all concerns identified during the?Medication Pass Audits, including re-training of the nurse and/or medication aide. The Administrator will review the Medication Pass Audits weekly x 4 weeks to ensure all concerns are addressed. The Interdisciplinary Team, including, the DON, ADON, Minimum Data Set (MDS) nurse, and Nurse Supervisor will review progress notes 5 x week x 6 weeks then monthly x 2 months. This audit is to identify any documentation related to a resident with an acute change from a significant medication error to ensure the resident was assessed, interventions were initiated, and the physician was notified for further recommendations. The Director of Nursing will immediately address all areas of concerns identified during the audit, including resident assessment, notification of the physician for further recommendations with documentation in the electronic record, and staff re-training. The Administrator will review the progress note audit weekly x 6 weeks then monthly x 2 months to ensure all concerns were addressed. The Interdisciplinary Team, including, the DON, ADON, Minimum Data Set (MDS) nurse, and Nurse Supervisor will review incident reports weekly x 6 weeks then monthly x 2 months. This audit is to identify any medication administration concerns resulting in medication errors to ensure appropriate interventions were initiated, the physician notified, and the resident assessed as indicated. The Director of Nursing will immediately address concerns identified during the audit, including resident assessment, notification of the physician for further recommendations with documentation in the electronic record, and staff re-training. The Administrator will review the incident report audit weekly x 6 weeks then monthly x 2 months to ensure all concerns are addressed. The Administrator/DON will forward the results of the Medication Pass Audits, Progress Note Reviews, and Incident Report review to the Quality Assurance Performance Improvement (QAPI) Committee including the Medical Director, DON, Administrator, Social Worker, Dietary Manager, ADON, Therapy Director, and Activity Director, monthly x 4 months. The QAPI Committee will meet monthly x 4 months and review the Medication Pass Audits, Progress Note Reviews, and Incident Report review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. Alleged Compliance Date: 01/18/24 Validation of the corrective action was completed on 02/8/24. This included staff interviews with nurses regarding the 6 rights of medication administration to include resident identification prior to administration of medication as well as observatio[TRUNCATED]