**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, medical record review, hospital record review, facility policy review, medication manufacturer guideline review and interview, the facility failed to ensure Resident #94 was free of a significant medication error. Actual Harm occurred beginning on 12/12/24 when Resident #94, who had a diagnosis of schizoaffective disorder, returned from the hospital with orders to continue the medication, Perphenazine, an anti-psychotic; however, Registered Nurse (RN) #604 and Licensed Practical Nurse (LPN) #601 failed to transcribe the order, or notify Resident #94's guardian and/or Psychiatrist #608 of the medication not being continued. As a result, Resident #94 had an exacerbation of symptoms including being impulsive, non-adherent to care, and had an increase in delusions. Resident #94 began having the delusion other residents were peeing on him and began to isolate in his room due to fear. Resident #94's guardian stated she voiced her concerns regarding the increased behaviors repeatedly (to staff) including at a care conference, 03/21/25, where it was identified Resident #94 was not receiving the Perphenazine. Resident #94 was then restarted on a low dose of Perphenazine and Psychiatrist #608 implemented a plan to gradually increase the dose while monitoring for improvement. This affected one resident (#94) of three residents reviewed for medication administration. The facility census was 150. Findings include: Review of the medical record for Resident #94 revealed an admission date of 08/28/24 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and schizoaffective disorder. Review of a Letter of Guardianship dated 03/07/23 revealed Resident #94 was deemed incompetent per Probate Judge #611 and awarded Resident #94's sister guardian of person indefinitely. Review of the admission physician orders on 08/28/24 revealed Resident #94 had an order for Perphenazine four (4) milligrams (mg) one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime. Review of the care plan dated 09/05/24 revealed Resident #94 experienced alteration in mood and/or behavior: feeling tired, having little energy, and feeling down. Resident #94 could be sexually inappropriate with staff. Interventions included allowing the resident to vent, validating the resident's feelings as needed, attempting to determine what triggers the behaviors, attempting to identify triggers, encouraging communication, and encouraging to keep in contact with family. There was nothing in the care plan regarding Resident #94 having delusional behaviors including stating other residents were peeing on him. Review of the care plan dated 09/05/24 revealed Resident #94 was at risk for adverse effects related to psychoactive medications as he had schizoaffective disorder and his medications included Perphenazine. Interventions included assessing behaviors for which drugs were being given for, assessing for adverse effects of medications, giving medications as ordered, psych evaluations and treatment as indicated, and reporting changes in behaviors. Review of the nursing note dated 12/11/24 at 11:34 A.M. and completed by LPN #613 revealed Resident #94 had complained of sharp and intermittent chest pain. He was transferred to the hospital for evaluation and subsequently admitted . Review of the Discharge Summary- Encounter Notes dated 12/12/24 at 11:06 A.M. and completed by Hospital Physician #610 revealed Resident #94 was admitted to the hospital on [DATE] due to hypertension, and he was discharged on 12/12/24. Hospital Physician #610 ordered to hold his Lisinopril (medication used to treat high blood pressure) and added Amlodipine (medication used to treat high blood pressure) instead. There were no active hospital problems, and his condition improved. The discharge summary included his discharge medications which also included starting Amlodipine 5 mg one tablet by mouth once a day and continuing taking the following medications which included perphenazine. The discharge summary listed to stop taking only one of his medications which was Lisinopril 5 mg tablet. The discharge summary also included prior to admission Resident #94's medications which also included Resident #94 was taking Perphenazine 4 mg by mouth once a day in the morning and 8 mg at bedtime. Review of the After Visit Summary dated 12/12/24 revealed Resident #94 was to start taking Amlodipine 5 mg one tablet by mouth once a day. The medication list had a list of medications Resident #94 was to continue upon discharge which included Perphenazine 4 mg in the morning and 8 mg at bedtime. There was a handwritten X over the Perphenazine. The medication list listed all the other medications that Resident #94 was to continue and there was a handwritten checkmark by each medication. The medication list revealed the facility was to change how Resident #94 took the following medication: acetaminophen (analgesic) two tablets by mouth every six hours as needed for pain. Review of the nursing note dated 12/12/24 at 3:35 P.M. and completed by LPN #601 revealed Resident #94 was re-admitted back to the facility. Resident #94 was diagnosed with chest pain. The note included Primary Care Physician (PCP) #612 was informed of all orders and verified. The note revealed a comprehensive evaluation of admission orders including evaluation of pre-admission medications had been completed. Comparisons of resident's medications taken prior to admission, to those prescribed upon admission have been reviewed using available records, transfer documents, discharge summaries, resident/family discussions, recent history and physical, medication lists, and/or progress notes. Medications were reviewed to identify and potentially prevent significant medication adverse consequences as soon as possible. The note revealed a care conference was offered upon admission, and referral to social service for scheduling. Baseline care plan and admitting paperwork was obtained and agreed. Review of the Interdisciplinary Team (IDT) Plan of Care Review Summary dated 12/27/24 revealed the team included but not limited to Licensed Social Worker (LSW) #600, Director of Nursing (DON), Administrator, Assistant Director of Nursing (ADON)/LPN #603 and Resident #94's guardian (by phone) met and discussed the guardians recent concerns, answered questions, discussed continuous positive airway pressure (CPAP) machine care, smoking, and recent weight loss. The notes revealed no revisions were made to the care plan. There were no other details noted on the notes including review of recent hospitalization (12/11/24) and/or medications including Resident #94 not being on Perphenazine. Review of the nursing note dated 01/02/25 at 11:14 P.M. and completed by the DON revealed the IDT reviewed behaviors as well as family concerns voiced. Resident #94 continued to be sexually inappropriate at times. Review of the nursing note dated 01/08/25 at 1:16 P.M. and completed by the DON revealed the IDT reviewed behaviors as well as family concerns. Resident #94 continued to be sexually inappropriate. Review of the IDT Plan of Care Review Summary dated 01/10/25 revealed the team included but not limited to LSW #600, DON, ADON/LPN #603, Resident #94's guardian and Resident #94 discussed concerns regarding communication, therapy, staffing, nails too long, electric wheelchair, business office concerns regarding cigarettes and account, showers, shower times, call lights being answered, cleaning equipment, clothing, and activities. There were no other details noted on the notes including review of medications. Review of the nursing note dated 01/10/25 at 10:05 A.M. and completed by the DON revealed the IDT reviewed care conference as family's concerns voiced were histrionic with no current similar complaints since concerns were addressed. The note revealed Resident #94's family often brought up concerns as if they were new; however, the concerns were already addressed when clarified. The note revealed the family reported Resident #94 was impulsive, non-adherent with care including hygiene, getting out of bed, and getting dressed. The note also revealed the family reported Resident #94 was more impulsive around smoke time and would run people down to get to the smoke pass. Review of the nursing note dated 01/17/25 at 10:15 A.M. and completed by the DON revealed the IDT reviewed the resident's behaviors as well as family concerns. Resident #94 continued to be sexually inappropriate. Resident #94 remained impulsive and was non-adherent with care despite staff education and encouragement. Review of the nursing note dated 02/03/25 at 1:33 P.M. and completed by the DON revealed the IDT reviewed behaviors, and Resident #94 continued to be sexually inappropriate. Resident #94 remained impulsive, and non-adherent with care despite staff education and encouragement. Review of the nursing note dated 02/07/25 at 6:40 P.M. and completed by the DON revealed Resident #94 was being sexually inappropriate with staff. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of four out of 15. During the assessment period he had other behavioral symptoms not directed towards others one to three days of the seven-day assessment reference period. The MDS revealed the resident was not on anti-psychotic medication. Review of the IDT Plan of Care Review Summary dated 03/21/25 revealed the team included but not limited to LSW #600, DON, ADON/LPN #603, Resident #94's guardian and the resident discussed psych medications, and when Resident #94 was going to smoke in the dining room, Resident #94 stated, they are pissing on me as he was experiencing delusions. The note revealed Resident #94 had a decrease in his mood as he was more accusatory. The note included PCP #612 restarted his psych medication (Perphenazine) at a low dose. Review of the nursing note dated 03/21/25 at 11:47 A.M. and completed by ADON/LPN #603 revealed PCP #612 gave new orders to restart Resident #94 on Perphenazine at lower dose: Perphenazine 2 mg by mouth twice a day and follow up with Psychiatrist #608. Resident #94's guardian was notified of medication change. Review of the nursing note dated 04/02/25 at 1:55 P.M. and completed by the DON revealed the IDT reviewed Resident #94's behaviors as well as family concerns voiced. Resident #94 remained impulsive, and non-adherent with care at times including getting dressed, getting out of bed, and hygiene. Resident #94 remained paranoid and delusional as he thought peers were urinating on him in the smoke room. Review of the nursing note dated 04/15/25 at 9:21 A.M. and completed by ADON/LPN #603 revealed Resident #94 had a telehealth appointment with Psychiatrist #608 and his mood was discussed including how the last two days he was coming down to the dining room for meals. Psychiatrist #608 increased his Perphenazine to 2 mg by mouth in the morning and 4 mg at bedtime for two weeks and then increase the Perphenazine to 4 mg by mouth twice daily. The note revealed Resident #94's guardian was present during the appointment. Review of Hospital Ombudsman #609's letter dated 04/16/25 to Resident #94's guardian revealed she was writing in response to the telephone conversation regarding Resident #94 and what the hospital sent to the facility regarding his medication. The letter revealed from review the medication in question (Perphenazine) was continued, and the hospital had no record this medication was discontinued. Review of the nursing note dated 05/10/25 at 12:15 P.M. and completed by LPN #601 revealed staff reported to the nurse that while in the dining room Resident #94 made a delusional statement as he was stating a peer was urinating on him. Resident #94 was reassured that peer was not urinating on him and offered to assist resident to the bathroom which he declined. On 05/14/25 at 7:46 A.M. Resident #94 was observed up in his wheelchair in his room displaying no behaviors and was smiling. At the time of the observation, an interview with the resident revealed he started the day off good as he was up and ready to eat. He denied any issues with feeling depressed or anxious at this time. He revealed he slept well and had a good appetite. During the interview, the resident had no knowledge regarding what medications he took. Interview on 05/14/25 at 9:23 A.M. with LSW #600 revealed she was responsible for setting up and arranging care conferences. She revealed Resident #94 had a care conference 12/27/24, 01/10/25, and 03/21/25. She revealed she did not recall any discussion regarding the resident's behaviors brought up by the family on 12/27/24 or 01/10/25. She revealed the family did bring up concerns regarding his behaviors on 03/21/25 that included Resident #94 acting more tired, sluggish, and his responses were not as quick. She revealed ADON/LPN #603 printed off the medication list, and Resident #94's guardian realized Resident #94 was no longer on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime. She revealed Resident #94's guardian stated that she was never informed this had been discontinued. PCP 612 was notified of the concern and ordered the Perphenazine back at a low dose and to follow up with Psychiatrist #608. On 05/14/25 at 9:23 A.M. and 11:17 A.M. an interview with LPN #601 revealed she routinely worked on the unit Resident #94 resided on. She recalled when Resident #94 returned from the hospital on [DATE] it was during shift change. She stated she did not look at the orders including to identify who had placed the X over the Perphenazine and/or place check marks next to the other medications. She revealed LPN #602 had transcribed Resident #94's orders. She revealed LPN #601 reviewed her nursing note entry dated 12/12/24 at 3:35 P.M. that stated she informed PCP #612 of the orders, verified the orders, and she performed a comprehensive evaluation of admission orders including evaluation of pre-admission medications, and comparisons of Resident #94's medications taken prior to admission. LPN #601 verified she did not look at the admission orders and/or compared Resident #94's medications that he was taking prior to admission. She verified she did not know Resident #94's Perphenazine had not been restarted. She verified she did not notify PCP #612 regarding Resident #94 not being on Perphenazine as she again verified, she did not look at the orders. When asked how she verified the medications with PCP #612 if she did not look at the medications she stated, yes, I did call the physician but no I did not share that he was not on that medication as I did not know as I did not look at the orders. She then revealed Registered Nurse (RN) #604 would have transcribed the orders and LPN #602 would have completed the double check of the orders. She revealed the nursing note she entered was a generic note used on all admissions and readmissions. On 05/14/25 at 10:17 A.M. an interview with ADON/LPN #603 revealed Resident #94 followed up with Psychiatrist #608 by telehealth as Resident #94's guardian came into the facility and completed solo with the physician. She verified Psychiatrist #608 was not notified Resident #94 had not been administered the Perphenazine since his return from the hospital on [DATE]. She revealed Resident #94's guardian requested the care conference on 03/21/25 because she was concerned about Resident #94's behaviors as he was not going to the dining room as much and had other behaviors. She revealed at the care conference, on 03/21/25, the facility discovered Resident #94 was no longer on the Perphenazine and had not been receiving the medication since his re-admission from the hospital on [DATE]. She stated she was unsure why the medication was stopped, as she did an investigation and nobody seemed to own up to who put the X over the Perphenazine. She revealed the investigation was completed verbally and she had nothing in writing such as witness statements. She verified yes, it fell somehow through the cracks, and I have no idea how. She verified LPN #601 should not have documented in the nursing note she had verified the orders with the physician if she did not look at the orders. She verified LPN #601 should have reviewed Resident #94's orders, compared the orders to his previous orders and noticed that the perphenazine was not restarted especially since she was an everyday nurse on the unit Resident #94 resided on. She verified previously at care conferences medications were not reviewed unless there was a need. She also verified Resident #94's guardian would not have had a medication list to review with Psychiatrist #608 during his telehealth appointment; therefore, Psychiatrist #608 would not have been aware Resident #94 was not on Perphenazine. She stated, going forward, the facility was doing things differently as now all re-admissions were reviewed by management including reviewing all their discharge medications, and now she was sitting in on Resident #94's telehealth appointments with Psychiatrist #608, and she was bringing a medication list to all care conferences. On 05/14/25 at 10:53 A.M. an interview with LPN #602 revealed Resident #94 returned from the hospital on [DATE]. She stated she received in report from LPN #601 that Resident #94 had returned and the orders were in the computer but needed double checked. She stated she assumed LPN #601 had put the orders in but was unsure. She revealed she did not receive anything in report that Resident #94 was no longer on Perphenazine. She could not remember if the orders had checkmarks or an X by or on them but that she did not place any marks on the orders. She remembered double checking the orders but does not recall anything regarding Resident #94's Perphenazine order. On 05/14/25 at 11:46 A.M. an interview with RN #604 revealed Resident #94 was only admitted for one day at the hospital and had returned. She remembered transcribing the resident's medication orders and stated, I would have just followed to a T putting the orders in. She revealed she remembered marks on the discharge orders but could not say for sure if they were checkmarks or an X. She revealed she could not say if the Perphenazine had an X over it or not. She was not aware the resident was on Perphenazine previously and stated she does not look at what medications a resident was on prior to admission as she just goes down the list and transcribes what is on the list from the hospital. She revealed she never informed PCP #612 or Resident #94's guardian that he was not on Perphenazine or followed-up to question the Perphenazine. On 05/14/25 at 1:10 P.M. an interview with the DON verified her nursing notes dated 01/02/25 and 01/08/25 revealed Resident #94 was sexually inappropriate, and on 01/10/25 the family reported Resident #94 was impulsive, non-adherent with care including hygiene, getting out of bed, and getting dressed. She also verified on 01/10/25 the family reported Resident #94 was more impulsive around smoke time and would run people down to get to the smoke pass. She verified her nursing note entries dated 01/17/25 and 02/03/25 revealed the behaviors continued. Then, she verified on 03/21/25 the IDT team met with Resident #94's guardian regarding his behaviors: when Resident #94 was going to smoke in the dining room Resident #94 stated, they are pissing on me as he was experiencing delusions and decrease in his mood as he was more accusatory. She verified they reviewed the medication list (at this time) and determined Resident #94 was no longer on his Perphenazine. She revealed Resident #94's guardian often brings up things from the past that already had been addressed. She revealed on the hospital admission orders there was an X over the Perphenazine and that the nurses at the facility stated they had not placed the X as she felt it may have been done by the hospital. She revealed the nurses assumed the X meant to discontinue the medication. She revealed LPN #601 documented that the medications were verified with PCP #612. The DON was informed LPN #601 stated that she did contact PCP #612 and verified the orders but also verified she had never reviewed the hospital discharge orders. The DON was questioned how LPN #601 verified if she did not review the orders. She replied, I do not know. She also verified Resident #94 was on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime since admission, 08/28/24 and asked if nursing judgement would not be in best practice to ensure Psychiatrist #608 was notified prior to stopping the medication abruptly. She revealed, not like hospitals do not do that. She verified there was no documentation Psychiatrist #608 was notified of Resident #94's Perphenazine being discontinued 12/12/24 and of his increase in behaviors including delusions until it was discovered on 03/21/25 that he no longer was on his Perphenazine. On 05/14/25 at 1:37 P.M. an interview with Resident #94's guardian revealed she visited frequently, three to four times a week. The guardian revealed (following the December hospitalization) Resident #94 began having increased delusions with paranoia. Resident #94 felt other residents were peeing on him as he felt his clothing was wet when it was not. This was an old behavior she had not seen for years. She revealed the resident wanted to have his door shut to his room because he was afraid the residents would come in his room and pee on him. She revealed he also was having issues controlling his anger and trying to isolate himself. She revealed his behavior got more and more bizarre. She stated she brought up her concerns to the facility multiple times regarding the resident's behaviors and felt facility staff were just blowing her off. She requested another meeting on 03/21/25 to discuss his behavior and that was when she found out on 12/12/24 when the resident came back from the hospital, the facility never restarted his Perphenazine. She revealed he had been on Perphenazine 4 mg one tablet by mouth in the morning and Perphenazine 4 mg two tablets by mouth at bedtime for a long time and the facility just cold turkey stopped the medication. She stated on 12/12/24, she was notified he returned from the hospital but was never told that his Perphenazine was not restarted or she would have ensured Psychiatrist #608 was notified. The facility never informed Psychiatrist #608 that the Perphenazine was discontinued. She revealed she always participated in Psychiatrist #608 telehealth appointments at the facility, and the facility was aware of the appointment but never sat in and/or shared a medication list with Psychiatrist #608. She revealed on 12/17/24 (after his readmission) they had a telehealth appointment with Psychiatrist #608, and they never shared Resident #94 was no longer on Perphenazine, so Psychiatrist #608 was not aware at that appointment as Psychiatrist #608 assumed he was on the same medication. She revealed she felt this was neglectful as for months the resident was displaying an increase in delusions, and the facility kept ignoring the family advocating that something was wrong with Resident #94. The resident's guardian stated she felt the resident should not have had to live for months the way he did. On 05/14/25 at 3:39 P.M. an interview with Psychiatrist #608 verified the facility did not notify him that Resident #94's Perphenazine was discontinued on 12/12/24, and Resident #94 did not receive the Perphenazine for several months. He revealed Resident #94 had symptom exacerbation and now he was raising the medication and tracking whether Resident #94 improved with the medication increase. Review of information obtained from drugs.com dated 08/03/23 revealed Perphenazine was an anti-psychotic medication used to treat psychotic disorders such as schizophrenia. The guidelines indicated not to stop using Perphenazine suddenly or that a person could have unpleasant symptoms such as nausea, vomiting, dizziness, or tremors. Review of the facility policy labeled, Physician Orders- Admission dated 07/14/10 revealed the admission order would be received by licensed nurses and would be confirmed in writing by the prescriber and attending physician. The policy revealed the licensed nurse reviewed the orders from the transfer record from the acute care hospital or other entity. The policy revealed a call was placed to the admitting physician to confirm the transfer orders and request additional orders as needed. The policy revealed a nursing note was to be documented to authenticate the admission orders: admission orders reviewed and approved per physician. The policy revealed telephone orders would be written for changes, clarifications, or orders made in addition to the original transfer orders. Review of the facility policy labeled, Physician Orders- Transcription dated 07/27/23 revealed the purpose of the policy was to ensure admission and other orders were received and transcribed in accordance with professional standards of practice. The policy revealed physician orders would be accurately transcribed and initiated in accordance with professional standards of practice. The deficient practice was corrected on 04/14/25 when the facility implemented the following corrective actions: • On 03/21/25 the DON provided immediate education to the facility ADON staff (following the care conference where Resident #94's sister questioned why his Perphenazine was discontinued); education included direction to clarify any orders that were changed during audit of admission orders to ensure accuracy of new orders. • Beginning 03/27/25 the facility implemented weekly risk management audits and reviews to be completed by the facility interdisciplinary team (IDT) on all admissions/readmissions. • On 04/14/25 the DON provided education during an all staff meeting related to reviewing admissions/readmissions reviews, 24-hour follow-up, contacting hospital with any changes to ensure accuracy. • Between 04/14/25 and 05/19/25 no additional significant medication errors were identified to have occurred. This deficiency represents non-compliance investigated under Complaint Number OH00165518.