**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, nurse practitioner (NP), and Physician interviews, the facility failed to notify the physician or the nurse practitioner that an anti-seizure medication (lacosamide) was not available for administration for 1 of 1 resident reviewed for notification of change (Resident #244). The facility failed to notify the NP or the Physician that lacosamide was not available for administration on 4/30/2022, 5/1/2022, 5/4/2022, 5/8/2022, 5/24/2022, and 5/26/2022. Resident #244 was hospitalized with cardiac issues on 5/11/2022 and with seizure activity on 5/27/2022. Findings included: Resident #244 was admitted to the facility 4/27/2022 at 11:45 PM with diagnoses to include stroke, seizures, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #244 to be severely cognitively impaired. The MDS documented Resident #244 had a percutaneous endoscopic gastrostomy (PEG) tube for feeding and medications. The MDS documented Resident #244 had seizure disorder. The medical record for Resident #244 was reviewed and physician order dated 4/27/2022 ordered lacosamide 10 milligrams per milliliter (mg/ml) give 15 ml (150 mg) by PEG tube every 12 hours for seizures. The Medication Administration Record (MAR) for April 2022 was reviewed. The documentation for lacosamide were as follows: 4/30/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #13 for 4/30/2022 documented at 10:07 AM on hold from pharmacy without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. 5/1/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #12 for 5/1//2022 documented at 10:32 AM (lacosamide)10 mg on order from pharmacy, not available. There was no documentation indicating the NP had been notified the medication was not available. 5/1/2022 9:00 PM dose, 9 (other, see progress notes). Nursing progress notes dated 5/1/2022 at 10:47 PM documented medication not available without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. 5/4/2022 9:00 PM dose 5. Nursing progress notes written by Nurse #13 dated 5/4/2022 at 9:50 PM documented, (lacosamide)10 mg on order from pharmacy, not available. There was no documentation indicating the NP had been notified the medication was not available. 5/8/2022 9:00 PM dose 9. Nursing progress notes dated 5/8/2022 at 11:06 PM documented medication not available without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. Documentation from 5/9-5/11/2022 included NP notification. Resident #244 was readmitted from the hospital 5/23/2022 with a diagnosis of sinus pause (a cardiac arrhythmia when the heartbeat pauses or stops). A physician order dated 5/23/2022 ordered lacosamide 10 mg/ml administer 15 ml (150 mg) by PEG tube every morning and at bedtime related to seizure activity. The MAR for May 2022 was reviewed and the documentation for lacosamide were as follows: 5/24/2022 9:00 AM dose 9. Nursing progress notes dated 5/24/2022 at 1:45 PM documented not in stock, without specific medication identified. There was no documentation indicating the NP had been notified the medication was not available. 5/26/2022 9:00 PM dose 5. No nursing progress note was documented. Nurse #11 was assigned to Resident #244 on this date. There was no documentation indicating the NP had been notified the medication was not available. Documentation 5/25/2022 included NP notification. An interview was conducted with Nurse #10 on 10/12/2022 at 3:51 PM. Nurse #10 reported that he had provided care to Resident #244 and had administered medications to him. Nurse #10 reported that he did not specifically remember lacosamide for Resident #244 and he could not remember if he talked to the DON or the NP regarding the availability of doses. An interview was conducted with Nurse #12 on 10/12/2022 at 4:38 PM. Nurse #12 reported she vaguely remembered Resident #244 but did not remember the medication administration. Nurse #12 reported that if her documentation did not say she contacted the NP, she had not called the NP to notify the lacosamide was not available. Nurse #11 was interviewed on 10/12/2022 at 5:02 PM. Nurse #11 reported that he was an agency nurse and he had provided care to Resident #244. Nurse #11 reported he told the DON Resident #244 did not have lacosamide available for administration but was not certain of the date. An interview was conducted with Nurse #13 on 10/13/2022 at 9:38 AM. Nurse #13 reported that lacosamide was not available and she notified the NP the medication was not available. Nurse #13 reported she had not reported the medication was not available to the DON. Nurse #13 reported she was unable to remember which NP she had contacted and on what date she had notified the NP the lacosamide was not available. Nurse #13 reported she must have forgotten to document she contacted the NP on 4/30/2022 and 5/4/2022. Nurse #9 was interviewed on 10/12/2022 at 12:36 PM. Nurse #9 reported she had provided care to Resident #244, and she had not been able to administer lacosamide to Resident #244 because the medication was not in the facility. Nurse #9 reported she had notified a NP, but she was not certain of the date she contacted the NP, or if she spoke to the facility NP or the on-call NP. Nurse #9 reported that she had not notified the Director of Nursing (DON) that lacosamide was not available for administration to Resident #244. Nurse #9 initials were on the MAR for Resident #244 on 4/28/2022, 4/29/2022, 5/7/2022, and 5/8/2022. An interview was conducted with the NP on 10/12/2022 at 1:53 PM. The NP reported that she was not notified by any nursing staff that the facility had not administered lacosamide to Resident #244 until 5/27/2022. The NP explained that lacosamide was a controlled medication and prescription had to be handwritten and submitted to the pharmacy for the medication to be filled. The NP reported on 4/23/2022 she had written a handwritten prescription and it was faxed to the pharmacy and she believed that Resident #244 was receiving the lacosamide for seizures because she was not notified lacosamide had not been delivered by the pharmacy. The NP reported she was notified on 5/27/2022 that Resident #244 had not received lacosamide for 3 days. The NP reported it was not until later (uncertain of date) she was notified that Resident #244 had not received any lacosamide in the facility from admission until 5/28/2022. The NP stated missing the lacosamide was a significant medication error that could have resulted in brain injury related to uncontrolled seizure activity. The NP was interviewed again 10/12/2022 at 3:06 PM. the NP reported that abruptly stopping lacosamide could also cause significant cardiac issues. The NP reported if she had been notified of the issues with obtaining the medication, then she could have had discussions with the family, the facility, and the physician about changing or modifying medications. The facility physician (MD) was interviewed on 10/12/2022 at 3:13 PM. The MD reported he was not aware Resident #244 had not received lacosamide as ordered until today (10/12/2022). The MD reported that not administering the lacosamide for Resident #244 was a significant and serious error that could have impacted his cardiac health and his neurological health. The MD explained that after a stroke, some patients have seizure activity, and that was why Resident #244 required the medication lacosamide. The DON was interviewed on 10/12/2022 at 6:01 PM. The DON explained that when Resident #244 was admitted from the hospital on 4/23/2022 he did not have a handwritten prescription for lacosamide, and the NP wrote a prescription for the medication. The DON reported that the NP had written for tablets to be administered and Resident #244 required the liquid form for administration through the PEG tube. The DON reported there were complications from the pharmacy with the dosage of the medication that required clarification by the NP. The DON reported that she was not aware Resident #244 had not received lacosamide until 5/27/2022, 3 days after Resident #244 was readmitted to the facility from the hospital. The DON reported that Resident #244 was sent to the hospital for seizure activity and sent back to the facility. The DON reported that on 5/27/2022 the NP wrote another handwritten prescription for lacosamide, and it was sent to the pharmacy, and the medication was delivered on 5/28/2022. The DON reported that she notified Resident #244's family member about the medication error on 5/27/2022 and she started a plan of correction for the medication error. The Administrator was notified of the immediate jeopardy on 10/12/22 at 6:30 PM. The facility provided a plan of correction with a correction date of 6/15/2022. The plan of correction included F580: # 1 - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. (Lacosamide) was not available for resident upon admission. The patient missed his medication upon admit 4/27/2022 to 5/11/2022. The patient discharged to hospital on 5/11/2022 and returned from hospital on 5/23/2022. Patient had a delay in (lacosamide) again from 5/23/2022 until 5/27/2022. On 5/27/2022, the patient received his medication. Nursing administration self-identified this ongoing issue of medication availability, and put together a 4-step plan POC for both: 1. Notification to physician and/or nurse practitioner (NP) when medications are unavailable at med pass for follow-up 2. Medication availability in general The root cause of this issue upon the first admission, was that upon missing medications, the physician and/or NP was not notified of the need for the hard script related to the (lacosamide). The hospital did not send the patient with the hard script upon admit. The information was passed from shift to shift by nurses, and not to nursing administration for intervention and resolution. Upon readmission on 5/23, the root cause was that the discharging hospital did not send the hard script again (for lacosamide). The NP was notified and did provide a script; however, it was for tablets, versus a liquid format given that the patient has a PEG tube for medications. The NP was notified, then re-wrote the script for liquid dosing; however, pharmacy could not accept this prescription related to the dosage. (The prescription could not be split as it was a scheduled medication) The NP again was notified and re-wrote the prescription for(lacosamide) with the appropriate dosage which could be filled by the pharmacy. The pharmacy provided the medication in liquid form and the patient received the medication moving forward. The patient discharged on 6/5/2022. # - 2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All medications were reviewed by the Director of Nursing (DON) for lacosamide. No other residents in the facility were found to be ordered lacosamide. # -3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education given to all current nurses (fulltime, part time and agency staff) on process of obtaining medication (lacosamide) and/or generic when not available. Moving forward nurses on hire will also receive this education. This will include notifying the physician and/or non-physician practitioner (PA, NP) with any and each missed dose of (lacosamide), for follow-up. The protocol is as follows: 1. Notify MD or NP/PA of missed (lacosamide) at time of med pass if unavailable. 2. Ask for hold order, alternate order and/or determine what next steps are via the MD/NP/etc. 3. If physician and/or NP does not offer a hold/alternate order for (lacosamide), notify DON for further intervention and follow-up, up and including administrator, attending physician, medical director and/or pharmacy consultant until resolution. 4. Notify pharmacy of missed medication to determine root cause and resolution. # - 4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. DON will audit all patients who receive (lacosamide) to ensure adequate supply three times weekly x 4 weeks, then weekly x 4 weeks and monthly ongoing. If/when a (lacosamide) medication is missed, audit will be performed to determine if the proper and timely notification was done to MD/NP for hold order, alternate order and/or next steps. Any issues found will be corrected immediately, and any nurse found not to be in compliance with protocol for medication availability and notification will be re-educated and/or disciplined up to and including termination as needed. The results will be reported to the monthly Quality Committee for review and discussion to ensure compliance. Once the QA Committee determines the problem no longer exits, then review will be completed on a random basis. Date of compliance as of 6/15/22. The plan of correction was reviewed and validated 10/13/2022 and 10/14/2022 by interviews with nursing staff, including Nurse #1, Nurse #2, Nurse #3, and Nurse #4. Included in the validation was a review of the educational in-services, review of the monitoring and audits, and medication administration observations. F580 was in compliance on 6/15/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Nurse Practitioner (NP), and Physician interviews, the facility failed to administer an anti-seizure medication (lacosamide) as ordered by the physician for 1 of 1 resident reviewed for significant medication errors (Resident #244). Resident #244 missed 34 doses of lacosamide. The facility failed to administer lacosamide on 4/28/2022 to 4/30/2022, 5/1 to 5/11/2022; 5/23 to 5/27/2022. Resident #244 was sent to the emergency room from a physician appointment on 5//11/2022 with cardiac issues (and admitted for treatment) and was sent to the emergency room for evaluation after seizure activity on 5/27/2022. Findings included: Resident #244 was admitted to the facility 4/27/2022 at 11:45 PM with diagnoses to include stroke, seizures, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #244 to be severely cognitively impaired. The MDS documented Resident #244 had a percutaneous endoscopic gastrostomy (PEG) tube for feeding and medications. The MDS documented Resident #244 had seizure disorder. The medical record for Resident #244 was reviewed and physician order dated 4/27/2022 ordered lacosamide 10 milligrams per milliliter (mg/ml) give 15 ml (150 mg) by PEG tube every 12 hours for seizures. The Medication Administration Record (MAR) for April and May 2022 were reviewed. The documentation for lacosamide was as follows: 4/28/2022 9:00 AM dose, 5 (hold/see progress note). Progress notes for 4/28/2022 revealed that all morning medications were on hold and the NP was aware. This note was written by Nurse #9. 4/28/2022 9:00 PM dose was documented as administered. 4/29/2022 9:00 AM dose, 6 (hospitalized ). Nursing progress notes written by Nurse #9 dated 4/29/2022 documented that Resident #244 was sent to the hospital because he pulled out his PEG tube. The note documented Resident #244 returned to the facility at 11:00 AM, the morning medications were not administered at that time, and the provider (NP) was notified. 4/29/2022 9:00 PM dose was documented as administered by Nurse #11. 4/30/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #13 dated 4/30/2022 documented at 10:07 AM on hold from pharmacy without specific medication identified. 4/30/2022 9:00 PM dose was documented as administered. 5/1/2022 9:00 AM dose, 5. Nursing progress notes written by Nurse #12 dated 5/1//2022 documented at 10:32 AM (lacosamide)10 mg on order from pharmacy, not available. 5/1/2022 9:00 PM dose, 9 (other, see progress notes). Nursing progress notes dated 5/1/2022 at 10:47 PM documented medication not available without specific medication identified. 5/2/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/2/2022 at 12:59 PM documented hold, NP aware, without specific medication identified. 5/2/2022 9:00 PM dose 5. Nursing progress notes dated 5/2/2022 at 10:17 PM documented hold, NP aware, without specific medication identified. 5/3/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/3/2022 at 10:23 AM documented hold, NP aware, without specific medication identified. 5/3/2022 9:00 PM dose 5. Nursing progress notes dated 5/3/2022 at 9:46 PM documented hold, NP aware, without specific medication identified. 5/4/2022 9:00 AM dose was documented as administered by Nurse #13. 5/4/2022 9:00 PM dose 5. Nursing progress notes dated 5/4/2022 at 9:50 PM documented, (lacosamide)10 mg on order from pharmacy, not available. 5/5/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/5/2022 at 10:31 AM documented hold, NP aware, without specific medication identified. 5/5/2022 9:00 PM dose 5. Nursing progress notes dated 5/5/2022 at 9:16 PM documented hold, NP aware, without specific medication identified. 5/6/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/6/2022 at 1:18 PM documented hold, NP aware, without specific medication identified. 5/6/2022 9:00 PM dose 5. Nursing progress notes dated 5/6/2022 at 6:57 PM documented hold, NP aware, without specific medication identified. 5/7/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #4 dated 5/7/2022 at 1:25 PM documented hold, NP aware, without specific medication identified. 5/7/2022 9:00 PM dose was documented as administered. 5/8/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/8/2022 at 12:56 PM documented hold, NP aware, without specific medication identified. 5/8/2022 9:00 PM dose 9. Nursing progress notes dated 5/8/2022 at 11:06 PM documented medication not available without specific medication identified. 5/9/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/9/2022 at 10:01 AM documented hold, NP aware, without specific medication identified. 5/9/2022 9:00 AM dose 5. Nursing progress notes dated 5/9/2022 at 9:13 PM documented Med held, NP notified, without specific medication identified. 5/10/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/10/2022 at 1:42 PM documented hold, NP aware, without specific medication identified. 5/10/2022 9:00 PM dose 5. Nursing progress notes dated 5/10/2022 at 9:48 PM documented NP aware, hold, without specific medication identified. 5/11/2022 9:00 AM dose 5. Nursing progress notes written by Nurse #13 dated 5/11/2022 at 10:37 AM documented on hold, NP aware, without specific medication identified. Nursing progress notes dated 5/12/2022 at 1:49 AM documented Resident #244 had been admitted to the hospital. The hospital Discharge summary dated [DATE] documented Resident #244 had a history of cryptogenic stroke (a stroke with an unknown cause) and was hospitalized after a loop recorder (heart rhythm monitor) detected 5-17 second pause during the night on 4/2/2022. Resident #244 was seen in the cardiologist office on 5/11/2022 and referred to the hospital emergency department after that appointment. During transport to the hospital, it was noted Resident #244 had apnea (stopped breathing for several seconds). During the hospital stay, it was noted Resident #244 had second-degree heart block (electrical signals in the heart are disrupted, which can cause cardiac arrhythmias). The discharge note documented Resident #244 would continue to follow up with cardiology after discharge. Resident #244 was readmitted to the facility from the hospital 5/23/2022 with a diagnosis of sinus pause (a cardiac arrhythmia when the heartbeat pauses or stops). A physician order dated 5/23/2022 ordered lacosamide 10 mg/ml administer 15 ml (150 mg) by PEG tube every morning and at bedtime related to seizures. New orders for Resident #244 were entered into the electronic documentation system at 2:38 PM. A nursing progress note dated 5/23/2022 at 10:00 PM documented the NP was aware of Resident #244 readmission to the facility. The May 2022 MAR was reviewed and documentation for lacosamide was as follows: 5/24/2022 9:00 AM dose 9. Nursing progress notes dated 5/24/2022 at 1:45 PM documented not in stock, without specific medication identified. 5/24/2022 9:00 PM 5. A nursing note dated 5/25/2022 at 12:16 AM documented (lacosamide) 15 ml np aware, hold. 5/25/2022 9:00 AM dose 5. A nursing note written by dated 5/25/2022 written by Nurse #13 at 10:47 AM documented on hold NP aware without specific medication identified. 5/25/2022 9:00 PM dose was documented as administered by Nurse #10. 5/26/2022 9:00 AM dose 5. Nursing progress note dated 5/26/2022 at 1:25 PM written by Nurse #13 documented on hold, NP aware without specific medication identified. 5/26/2022 9:00 PM dose 5. Nurse progress note written by Nurse #11, dated 5/26/2022 at 11:27 PM documented med on hold np aware without specific medication identified. 5/27/2022 9:00 AM no documentation for missed dose of medication. A Nursing progress note dated 5/27/2022 at 4:37 PM documented Resident #244 was having a seizure during physical therapy, and he was sent to the hospital. An emergency department discharge note dated 5/27/2022 documented Resident #244 had been sent to the hospital for evaluation after an apparent seizure. The note documented when the medics arrived at the facility, Resident #244 was no longer having seizure activity. The note documented that Resident #244 had not received lacosamide for 3 days. Lacosamide was documented as administered on 4/28/2022 9:00 PM, 4/29/2022 9:00 PM by Nurse #11, 4/30/2022 at 9:00 PM, 5/4/2022 at 9:00 AM by Nurse #13, 5/7/2022 at 9:00 PM, and 5/25/2022 at 9:00 PM by Nurse #10. An interview was conducted with Nurse #10 on 10/12/2022 at 3:51 PM. Nurse #10 reported that he had provided care to Resident #244 and had administered medications to him. Nurse #10 was asked about dose of lacosamide that were documented as given on 5/25/2022 at 9:00 PM. Nurse #10 reported he did not specifically remember 5/25/2022, and he said that if the medication was not in the building, he may have mistakenly clicked that he gave the medication. Nurse #10 reported that he did not specifically remember lacosamide for Resident #244 and he could not remember if he talked to the DON or the NP regarding the availability of doses. Nurse #11 was interviewed on 10/12/2022 at 5:02 PM. Nurse #11 reported that he was an agency nurse and he had provided care to Resident #244. Nurse #11 reported when he attempted to administer the lacosamide to Resident #244, he discovered there was no lacosamide in the facility. Nurse #11 reported he did not know why he documented administering lacosamide to Resident #244 on 4/29/2022 because the medication was not in the building. Nurse #11 reported he told the DON Resident #244 did not have lacosamide available for administration, but he was not certain of the date he made the report. An interview was conducted with Nurse #13 on 10/13/2022 at 9:38 AM. Nurse #13 reported that she had provided care to Resident #244. Nurse #13 reported that lacosamide was not available and she notified the NP the medication was not available. Nurse #13 reported she had not reported the medication was not available to the DON. Nurse #13 reported she was unable to remember which NP she had contacted and on what date she had notified the NP the lacosamide was not available. Nurse #13 reported she was not certain why she documented she administered lacosamide on 5/4/2022 and reported she may have clicked off the medication on accident. Nurse #9 was interviewed on 10/12/2022 at 12:36 PM and she reported she had provided care to Resident #244, and she had not been able to administer lacosamide to Resident #244 because the medication was not in the facility. Nurse #9 reported she had notified a NP, but she was not certain of the date she contacted the NP, or if she spoke to the facility NP or the on-call NP. Nurse #9 reported that she had not notified the Director of Nursing (DON) that lacosamide was not available for administration to Resident #244. An interview was conducted with the NP on 10/12/2022 at 1:53 PM. The NP reported that she was not notified that the facility had not administered lacosamide to Resident #244 until 5/27/2022. The NP explained that lacosamide was a controlled medication and prescription had to be handwritten and submitted to the pharmacy for the medication to be filled. The NP reported on 4/23/2022 she had written a handwritten prescription and it was faxed to the pharmacy and she believed that Resident #244 was receiving the lacosamide for seizures because she was not notified lacosamide had not been delivered by the pharmacy. The NP reported she was notified on 5/27/2022 that Resident #244 had not received lacosamide for 3 days. The NP reported it was not until later (uncertain of date) she was notified that Resident #244 had not received any lacosamide in the facility from admission until 5/28/2022. The NP stated missing the lacosamide was a significant medication error that could have resulted in brain injury related to uncontrolled seizure activity. The NP was interviewed again 10/12/2022 at 3:06 PM. the NP reported that abruptly stopping lacosamide could also cause significant cardiac issues. The NP reported if she had been notified of the issues with obtaining the medication, then she could have had discussions with the family, the facility, and the physician about changing or modifying medications. The facility physician (MD) was interviewed on 10/12/2022 at 3:13 PM. The MD reported he was not aware Resident #244 had not received lacosamide as ordered until today (10/12/2022). The MD reported that not administering the lacosamide for Resident #244 was a significant and serious error that could have impacted his cardiac health and his neurological health. The MD explained that after a stroke, some patients have seizure activity, and that was why Resident #244 required the medication lacosamide. The DON was interviewed on 10/12/2022 at 6:01 PM. The DON explained that when Resident #244 was admitted from the hospital on 4/23/2022 he did not have a handwritten prescription for lacosamide, and the NP wrote a prescription for the medication. The DON reported that the NP had written for tablets to be administered and Resident #244 required the liquid form for administration through the PEG tube. The DON reported there were complications from the pharmacy with the dosage of the medication that required clarification by the NP. The DON reported that she was not aware Resident #244 had not received lacosamide until 5/27/2022, 3 days after Resident #244 was readmitted to the facility from the hospital. The DON reported that Resident #244 was sent to the hospital for seizure activity and sent back to the facility. The DON reported that on 5/27/2022 the NP wrote another handwritten prescription for lacosamide, and it was sent to the pharmacy, and the medication was delivered on 5/28/2022. The DON reported she started a plan of correction for the medication error. The Administrator was notified of the immediate jeopardy on 10/12/22 at 6:30 PM. The facility provided a plan of correction with a correction date of 6/15/2022. The plan of correction included F760: # 1 - Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. (Lacosamide) was not available for resident upon admission. The patient missed his medication upon admit 4/27/2022 to 5/11/2022. The patient discharged to hospital on 5/11/2022 and returned from hospital on 5/23/2022. Patient had a delay in (lacosamide) again from 5/23/2022 until 5/27/2022. On 5/27/2022, the patient received his medication. Nursing administration self-identified this ongoing issue of medication availability, and put together a 4-step plan POC for both: 1. Notification to physician and/or nurse practitioner (NP) when medications are unavailable at med pass for follow-up 2. Medication availability in general The root cause of this issue upon the first admission, was that upon missing medications, the physician and/or NP was not notified of the need for the hard script related to the (lacosamide). The hospital did not send the patient with the hard script upon admit. The information was passed from shift to shift by nurses, and not to nursing administration for intervention and resolution. Upon readmission on 5/23, the root cause was that the discharging hospital did not send the hard script again (for lacosamide). The NP was notified and did provide a script; however, it was for tablets, versus a liquid format given that the patient has a PEG tube for medications. The NP was notified, then re-wrote the script for liquid dosing; however, pharmacy could not accept this prescription related to the dosage. (The prescription could not be split as it was a scheduled medication) The NP again was notified and re-wrote the prescription for(lacosamide) with the appropriate dosage which could be filled by the pharmacy. The pharmacy provided the medication in liquid form and the patient received the medication moving forward. The patient discharged on 6/5/2022. # - 2 Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All medications were reviewed by the Director of Nursing (DON) for lacosamide. No other residents in the facility were found to be ordered lacosamide. # -3 Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Education given to all current nurses (fulltime, part time and agency staff) on process of obtaining medication (lacosamide) and/or generic when not available. Moving forward nurses on hire will also receive this education. This will include notifying the physician and/or non-physician practitioner (PA, NP) with any and each missed dose of (lacosamide), for follow-up. The protocol is as follows: 1. Notify MD or NP/PA of missed (lacosamide) at time of med pass if unavailable. 2. Ask for hold order, alternate order and/or determine what next steps are via the MD/NP/etc. 3. If physician and/or NP does not offer a hold/alternate order for (lacosamide), notify DON for further intervention and follow-up, up and including administrator, attending physician, medical director and/or pharmacy consultant until resolution. 4. Notify pharmacy of missed medication to determine root cause and resolution. # - 4 Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. DON will audit all patients who receive (lacosamide) to ensure adequate supply three times weekly x 4 weeks, then weekly x 4 weeks and monthly ongoing. If/when a (lacosamide) medication is missed, audit will be performed to determine if the proper and timely notification was done to MD/NP for hold order, alternate order and/or next steps. Any issues found will be corrected immediately, and any nurse found not to be in compliance with protocol for medication availability and notification will be re-educated and/or disciplined up to and including termination as needed. The results will be reported to the monthly Quality Committee for review and discussion to ensure compliance. Once the QA Committee determines the problem no longer exits, then review will be completed on a random basis. Date of compliance as of 6/15/22. The plan of correction was reviewed and validated 10/13/2022 and 10/14/2022 by interviews with nursing staff, review of the educational in-services, review of the monitoring and audits, and medication administration observations. F760 was in compliance on 6/15/2022.