**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed and open medical record review, hospital record review, review of patient handout information from Medscape.com, emergency medical services (EMS) records, policy review and interviews the facility failed to provide comprehensive, resident centered care to adequately manage and prevent worsening of cardiac conditions for Resident #50. This resulted in Immediate Jeopardy and serious life-threatening harm/death for Resident #50, who was admitted to the facility on [DATE] with a history of chronic heart failure, cardiomyopathy, ventricular tachycardia (with an implanted defibrillator), atrial fibrillation, hypertension, and hypokalemia (low blood potassium level) when the resident did not receive the correct physician ordered dose of diuretics or antiarrhythmic medications for his cardiac conditions upon admission to the facility. The resident also did not receive comprehensive, individualized care for his extensive cardiac history including monitoring for fluid volume overload (intake and output), monitoring of weights and use of anti-embolism stockings, related to congestive heart failure. Despite the resident's known history of hypokalemia, no potassium supplement was ordered on admission to the facility. Potassium supplements were ordered once the facility identified the resident had a critical (low) potassium level; however, the resident experienced vomiting after meals. The physician and/or certified nurse practitioner (CNP) were not notified of the resident's declining condition. On [DATE] the resident was found unresponsive. Cardiopulmonary resuscitation was initiated, however unsuccessful, and the resident passed away. Per the coroner's report the resident's cause of death was cardiopulmonary failure due to coronary artery disease and cardiomyopathy in addition to the significant condition of hypertension. In addition, a concern that did not rise to Immediate Jeopardy occurred when facility failed to ensure Resident #14 was provided a comprehensive, resident centered status-post surgery treatment plan upon admission to the facility and failed to provide wound care as ordered. This affected two residents (#14 and #50) of three residents reviewed for appropriate care and services. The facility census was 37. On [DATE] at 4:48 P.M. the Business Office Manager, Social Service Designee #145, Regional Director of Operation #700, [NAME] President of Clinical Operation #701, and Registered Nurse (RN)/Regional Director of Clinical Operations #180 were notified Immediate Jeopardy began on [DATE] when the facility failed to ensure Resident #50's admission physician orders were clarified regarding discrepancies with the resident's diuretic medication, Torsemide and the resident's prescribed anti-arrhythmic medications, Amiodarone and Mexiletine, resulting in the medications not being administered and/or not being administered as ordered. Additionally, the resident did not receive comprehensive, individualized care for monitoring of known extensive cardiac history including obtaining resident weights and intake and output daily. The resident's family requested lab work due to diuretic use and a known history of hypokalemia which revealed a critically low potassium level of 2.9 (normal range 3.5-5.1 millimole per liter (mmol/L). Oral potassium supplementation was ordered, however the resident experienced vomiting after meals which had the potential to affect the effectiveness of the potassium medication. The facility failed to notify the resident's physician of medication discrepancies/errors, and the resident's decline in condition resulting in the resident's death after unsuccessful CPR. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 6:47 A.M. Resident #50 expired in the facility. • On [DATE] at 6:21 P.M. RDCO/Registered Nurse (RN) #180 completed an audit of all 34 current resident's progress notes to ensure notification of a decline in resident condition was reported to the physician in the past 72 hours. Daily audits would begin on [DATE] and would be completed for the next three months by the Director of Nursing (DON) and/or designee for any change in condition and physician notification. • On [DATE] at 6:45 P.M. RN #180 reviewed/audited the medical records for two additional residents (#55 and #56), who had expired since [DATE] to review the residents' care. Residents (#55 and #56) were receiving Hospice services and death were expected. Daily audits would begin on [DATE] and would be completed by the DON and/or designee for three months for any resident who experiences an unexpected death. • On [DATE] RDCO/RN #180 reviewed the medical records for all new resident admissions since [DATE] who were still residing in the facility (Resident #6, #20, #54) to ensure orders were transcribed correctly from hospital discharge to facility admission. Daily audits would begin on [DATE] and would be completed by the DON and/or designee for new admission/readmissions daily for three months. RDCO #180 and/or designee would review Point Click Care (PCC) for any new or re-admissions for any medication error reports documented into the risk management in PCC by the DON/Assistant Director of Nursing (ADON) to ensure that an investigation of the error has been completed as needed. • On [DATE] at 9:56 P.M. the Administrator notified Medical Director #501 of the Immediate Jeopardy situation. • On [DATE] at 10:05 P.M RN #180 audited all current residents (#10, #30, #35 and #36) with a diagnosis of congestive heart failure (CHF) and discussed with Physician #501. The need for intake and output (I&O), weight orders, and anti-embolism stocking orders were discussed. Physician recommendations were ordered. Daily audits would begin on [DATE] and would continue for the next three months and would be completed by the DON and/or designee. Audits would include any new diagnoses of CHF for current residents or new admission with a diagnosis of CHF and would be discussed with the medical provider regarding the need for intake and output monitoring, weight orders, anti-embolism stockings and any other care needed related to the CHF diagnosis. • Beginning [DATE] 10:03 P.M. and concluding on [DATE] at 11:29 A.M. education was provided in person or via phone to eleven licensed nurses (Licensed Practical Nurse #103, #127, #129, #140, #149, #168 and RN #113, #124, #206, #703 and Agency RN #709) by RN #180, Assistant Director of Nursing (ADON)#704, and the Administrator. The education included the new process of two nurses verifying new resident admission orders to ensure the orders were transcribed correctly from the hospital discharge to admission to the facility; newly diagnosed or new admissions with CHF would be discussed with the medical provider regarding care of the resident with CHF, and reviewed the change of condition policy, and notification of the physician/CNP of medication omission/discrepancies/errors and notification of decline in resident condition. RN #180 and #704 followed-up with the nurses after the education to ensure there were no unanswered questions related to the education. • On [DATE] starting at 6:31 A.M. 14 of the facility 16 STNAs were educated in person and by via phone by ADON #704 and the Administrator on ted hose, change of condition, and I&0. Two STNAs (#711 and #712) would be educated prior to working their next scheduled shift. • ADON #704 was educated on [DATE] at 5:30 P.M., by RDCO #180 that residents who had an unexpected death would have a chart audit completed to ensure no corrective action/education was needed and reviewing CNP/physician progress notes to ensure orders are implemented or if there are any questions to contact the provider. • A new Medication Error policy and procedure created by VP of Clinical Services was reviewed by RDCO #180 and Medical Director #501 at 2:36 P.M. and would be implemented effective [DATE]. • ADON #704 was educated on the new Medication Error Policy on [DATE] at 2:45 P.M. by RDCO #180. Any medication error needed to be investigated and any interventions implemented as indicated and if any med error occurs it was added to risk management. • The DON/designee would review progress notes daily regarding resident and/or resident representative concerns and would address any concerns following the grievance process. The audits would begin on [DATE] and continue for three months. • The contracted staffing agency was sent education by the Administrator on [DATE]. Education would be added to the site for our building for the staff to review prior to picking up a shift and there was a Nursing/Agency communication book at the nurse's station for them to review prior to the shift starting. The DON/designee would ensure Agency staff have reviewed education by contacting them once they have arrived at the facility and getting a verbal acknowledgement that they have reviewed. • Starting [DATE] all new staff would be verbally educated and on the above education of what to do if a medication error occurs, what to do a patient has CHF, what to do if a family has concerns, what to do if there was a change in condition with a patient and the process of new admission orders by the DON/designee during new hire orientation. • On [DATE] at 10:15 A.M. the previously identified 11 nurses were educated by Interim ADON #704 and RDCO#180 on Medication Error policy in person and via phone. • Audit findings will be reviewed weekly by the QAPI Committee with further recommendations as needed for eight weeks. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings included: 1. Closed record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses including chronic systolic heart failure, cardiomyopathy, hypertension, ventricular tachycardia with an implanted cardiac defibrillator (a small battery-operated device implanted in the chest that detects dangerous, irregular heart rhythms), atrial fibrillation and hyperlipidemia (elevated cholesterol levels). Review of Resident #50's hospital discharge summary note dated [DATE] revealed the resident's chief complaint was vomiting and diarrhea. He was admitted in March of 2024 with heart failure, had weight gain in a few weeks post discharge and his Torsemide (diuretic medication) was increased to twice daily. The resident had heart failure with a reduced ejection fraction that was maintained on Torsemide and Metolazone (diuretics). The resident's blood pressure was 100/60 millimeters of mercury (mmHg) and 105/57 mmHg the day of discharge ([DATE]). He had no edema in the lower extremities and his potassium was 4.4 mmol/L (normal limits). The resident had a history of hypokalemia (low potassium). The resident's condition on discharge was noted to be improved. Further review of Resident #50's discharge summary revealed Torsemide 20 milligram (mg) twice daily was resumed, and patient tolerated well, the heart failure team was consulted for management of diuretics. The plan was to monitor closely as an outpatient and gradually resume his heart failure medication depending on his blood pressure and improvement of his diarrhea. The Torsemide was held today ([DATE]) since he was nothing by mouth (NPO). The resident had non-sustained ventricular tachycardia (abnormal beating of the ventricles that did not continue) with numerous episodes. Mexiletine dose increased to every eight hours post discharge, his potassium (laboratory) goal was greater than four (4.0) and Magnesium goal greater than two (2). Record review revealed the resident's hospital discharge medication list dated [DATE] did not include orders to continue the Torsemide twice daily as indicated in the hospital discharge summary note. However, the hospital discharge medication orders included to administer Amiodarone 300 milligrams (mg) daily and Mexiletine 150 mg every eight hours (antiarrhythmic medications). Review of Resident #50's facility general progress notes, authored by Registered Nurse (RN) #703, revealed on [DATE] male resident admitted to the skilled nursing home at 1:45 P.M. after a short acute care hospital stay. The resident was alert and oriented times three. The resident was a full code (advance directives) and he had a brief medical history including but not limited to paroxysmal atrial fibrillation, coronary artery disease, decreased ejection fraction of 20% (the heart was not pumping blood as strong as it normally would) and generalized weakness. Non-pitting edema noted to upper and lower extremities. The resident's lung fields were diminished at this time with a moist non-productive cough noted. The physician was made aware of the new admission, no orders were given other than to continue current regimen at this time until the resident could be seen by a provider. The resident weighed 123 pounds per mechanical lift. Record review revealed no evidence the resident's Torsemide was discussed or clarified with the physician at this time. Review of a skilled note, authored by RN #167 and dated [DATE] at 12:47 P.M., revealed the resident's blood pressure was 138/76 and pulse was 72 and regular. The resident had plus two pedal (feet) edema (an indentation in the skin that stays present for approximately two seconds and indicates there is fluid accumulation). No signs of shortness of breath or difficulty breathing. Lung sounds were clear. Review of general progress note authored by RN #167 dated [DATE] at 4:12 P.M. revealed the resident's power of attorney (POA) was in to visit and was concerned with resident's increased edema to his bilateral lower extremities. The note indicated the POA requested resident's the diuretic be restarted. Staff spoke to the doctor and a new order was received to give Torsemide 20 mg now and to re-start 20 mg daily. The note also indicated, will have the Certified Nurse Practitioner (CNP) come in and see resident for admission history and physical. Review of a dietary note, authored by Dietary Manager #706 and an addendum note added by Dietary Supervisor #705 dated [DATE], revealed the resident was on a cardiac diet and it was clarified with the facility for a no-added salt (diet). The resident's meal intakes were 25-50%. The resident's body mass index was 19.9 (low/underweight) and his current body weight was 123 pounds on [DATE]. The note indicated the resident was at risk for weight fluctuations due to fluid shifts per hospital notes. Review of Resident #50's nutrition/hydration plan of care initiated on [DATE] revealed no evidence the resident was at risk related to CHF. Interventions included to monitor meal intakes, labs, tolerance to diet, weights per the facility policy, and to provide diet and snacks per order/preference. There was no evidence to monitor intake and output (I&O) for the resident. Review of the progress note dated [DATE] and authored by CNP #500 revealed the resident was a pleasant male with a past medical history consisting of, but not limited to, paroxysmal atrial fibrillation, chronic kidney disease, recurrent bowel obstructions, coronary artery disease, heart failure with reduced ejection fraction maintained on Torsemide and Metolazone (this medication was not ordered on admission to the nursing facility) cardiomyopathy, hypertension, and dyslipidemia. The resident had been admitted in [DATE] to the hospital for heart failure exacerbation and acute kidney injury. He had weight gain a few weeks ago post discharge so his Torsemide was increased to twice daily. The resident's heart rate was irregular, and lungs sounds were diminished. No edema noted. The plan was to monitor input and output, edema, and blood pressure. The note indicated continue Torsemide twice daily, potassium supplement (the medical record did not contain an order for potassium), and knee-high ted hose (anti-embolism/compression stockings). Review of an email confirmation, dated [DATE], revealed CNP #500 faxed Resident #50's progress note to the facility Medical Records Clerk #106 on [DATE]. Review of Resident/Family Education note authored by Agency Licensed Practical Nurse (LPN) #707 dated [DATE] revealed the Nurse Practitioner (NP) #500 saw the resident and new orders were received to apply ted hose (anti-embolism/compression stockings) daily for edema. Review of Resident #50's admission laboratory results, dated [DATE], revealed the resident's potassium level was 3.7 mmol/L (below the goal of 4.0). Record review revealed no evidence the facility developed and implemented a comprehensive and individualized plan of care for CHF/Cardiac. However, on [DATE] there was a plan of care initiated for risk of altered fluid balance and the only intervention was to evaluate skin turgor. Further review of Resident #50's plan of care revealed on [DATE] a risk for ineffective peripheral tissue perfusion was initiated. The intervention included to evaluate capillary refill and evaluate skin color, temperature, and characteristics. Review of Resident #50's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a poor appetite or overate 7-11 days. The assessment revealed the resident exhibited no behaviors including rejection of care. He was independent with prior function of everyday activities. The resident required setup or clean up assistance with eating and was dependent on staff for toileting. He had an ostomy (urostomy) and frequently incontinent with bowel. The assessment revealed the resident had CAD, heart failure, hypertension, hyperlipidemia, and malnutrition. Hyponatremia, hyperkalemia, vomiting, and shortness of breath were marked no. Weight loss/gain was marked no or unknown and the assessment noted the resident was on a therapeutic diet. The resident was on diuretics. The resident, family, significant other, legal guardian, or other legal authorized representative had not participated in the assessment or goal setting. The resident's overall goal was to be discharged to the community per family. Review of Resident/Family Education note, authored by LPN #140 and dated [DATE] at 8:00 A.M., revealed the family was in to visit and requested a lab draw to check the resident's potassium level due to the resident having a history of hypokalemia and he was on Torsemide. The physician agreed. The lab test was obtained, and the family took the specimen to the lab to drop it off. The note indicated, will await results. Review of Resident/Family Education note authored by LPN #140 and dated [DATE] at 11:17 A.M., revealed the lab called back with a critical potassium level of 2.9 (hypokalemic). The provider (Physician #501) was notified, and new orders were received for Potassium Chloride 20 milliequivalent (mEq) by mouth three times a day and recheck levels on Tuesday ([DATE]). The family was visiting and aware of the new order. Review of Resident/Family Education note, authored by LPN #140 and dated [DATE] at 6:03 P.M., revealed the resident had a small emesis this evening. It was green in color. There was no documented evidence CNP #500, or Physician #501 were notified of the resident's emesis. Review of the resident's paper and electronic medical record revealed no evidence the resident's oral intake or urinary output (I & O) were being monitored as stated in CNP #500's progress note dated [DATE]. Review of Resident #50's medication administration record (MAR) and treatment administration record (TAR), dated [DATE], revealed no evidence the potassium supplement (20 mEq) was administered until ordered on [DATE] even though the potassium supplement was first noted in CNP #500's progress note dated [DATE]. There was no further notation of the potassium supplement until [DATE] when the resident's family requested a potassium level be completed and the results were critically low, and potassium replacement was ordered in oral form. Review of Resident #50's medication administration records dated 05/2024 revealed on [DATE] the resident only received 200 mg of Amiodarone (order from hospital was 300 mg daily) and he didn't receive any Amiodarone on [DATE]. The order was discontinued and re-written for 300 mg on [DATE]. The Mexiletine order was entered as twice daily from [DATE] to [DATE]. The resident received one dose on [DATE], one dose on the 20th due to the morning dose was not administered and two doses on the [DATE]. The order was for three times daily not twice daily from the hospital. The order was discontinued and re-written three times daily on [DATE]. Further review of Resident #50's MAR revealed no evidence the ted hose daily for CHF were applied per orders. In addition, review of the MAR revealed there was an order dated [DATE] to monitor for side effects of coronary artery disease (CAD) every shift such as chest pain with activity, heartburn, nausea, vomiting, shortness of breath, excessive sweating, dependent edema, alternation in color/warmth of extremities. The MAR revealed staff were to mark 0 if no signs or symptoms of side effects and + if signs and symptoms are present. If present, staff were to document and notify the physician. Review of the MAR revealed staff were handwriting initials on the MAR for monitoring instead of 0 or +. Further review of Resident #50's [DATE] TAR revealed the resident was to be weighed every Friday for monitoring until [DATE] then monthly. There was no evidence the resident was weighed on Friday [DATE] per order. Review of a skilled note dated [DATE] at 4:04 A.M. revealed the resident was assessed by RN #167. (Note- It was determined this date and time was inaccurate per interview with Registered Nurse (RN) #167 on [DATE] at 10:30 A.M. The RN reported the assessment was completed on [DATE] around 11:00 P.M. not on [DATE] at 4:04 A.M.). The residents blood pressure was 138/70, pulse 74 and regular, respiration was 18, oxygen saturation was 95% on room air, and documented he was alert to time, person, and place. The resident had ted hose ordered. Left and right pedal pulses were plus two and normal. No signs of difficulty breathing or shortness of breath. Denied indigestion, nausea, vomiting, diarrhea, constipation, or bowel incontinence. Skin warm and dry, color within normal limits, and turgor was normal. No changes in the pressure ulcer on the coccyx, right knee, or right ankle. The resident had impairment of range of motion of both upper and lower extremities. His gait was unsteady, and he had poor balance. No safety concerns noted. Review of Resident/Family Education note, authored by RN #206 and dated [DATE] at 5:00 A.M., revealed per State Tested Nursing Assistant (STNA) #110, she had provided incontinence care to the resident around 3:00 A.M. The note indicated the resident was pleasant and carried on a conversation with the STNA throughout the care. When the nurse entered the resident's room to administer medication as ordered, the resident was non-responsive, and no vitals were found. The resident's code status was checked, and he was a full code. Cardiopulmonary resuscitation (CPR) was initiated and 911 was called. Paramedics arrived. assessed the resident and stopped CPR. The resident's time of death was noted to be 5:46 A.M. Review of emergency medical services (EMS) report dated [DATE] revealed at 5:03 A.M. a call was received from nursing home that Resident #50 had coded, and CPR was in progress. At 5:11 A.M. the squad arrived on the scene and went to Resident #50's room and CPR was being done by nursing home staff. The resident was in bed, but with a backboard under him. The EMS report indicated nursing home staff continued high quality CPR using bag valve mask (BVM) for ventilation. The EMS hooked the resident up to a four-lead showing asystole. The RN reported the resident was last seen at 3:00 A.M. and was fine. The nurse came in around 5:00 A.M. to administer medication and found the resident in this condition. Unknown down time. Due to the residents' condition and unknown down time, it was decided the resuscitation efforts would be futile. CPR was discontinued at this time. The cardiac arrest etiology was presumed cardiac. Coroner #710 arrived on scene, report given, and care transferred. Review of Resident #50's death certificate dated [DATE] revealed immediate cause of death was cardiopulmonary failure due to CAD and cardiomyopathy. Another significant condition was hypertension per Local Coroner #708. Record review revealed the facility did not complete an investigation into the resident's unexpected death and there was no documented evidence of any medication error reports being filed for the medication errors involving Resident #50. Review of the facility incident log for [DATE] revealed no documentation of the medication errors related to potassium, Amiodarone or Mexiletine for Resident #50. Review of Resident #50's medical record revealed no evidence the physician was notified of the medication errors related to the potassium, Amiodarone or Mexiletine. Interview on [DATE] at 4:28 P.M., with Family Member (FM)/Power of Attorney (POA) #502 revealed she was an RN and had voiced concerns on [DATE] to the facility regarding Resident #50's edema and difficulty breathing and requested the facility call the physician regarding restarting the resident's diuretics. The POA stated the diuretics had been stopped in the hospital due to the resident vomiting and having diarrhea. She stated she also asked daily for staff to call the provider back to get orders for a potassium supplement due to the resident having a history of hypokalemia while on diuretics. The POA voiced concerns the nurses would not address her requests related to starting a potassium supplement until [DATE] when a nurse finally agreed to call the provider to obtain orders. FM #502 stated she also requested a potassium level be obtained as well since the resident had been on a diuretic for five days. FM #502 reported a potassium level was done on [DATE] (which was within normal level but lower than the resident's goal determined by his recent hospitalization) however the resident had only received one dose of the diuretic when that lab test was obtained. An additional lab test was obtained on [DATE], and the resident had a critical (low) potassium level. FM #502 reported the resident had vomiting, which she determined the nurses were not documenting all the vomiting episodes and she didn't believe the resident could keep the oral potassium down. During the interview, POA #502 shared the resident had passed away the following morning on [DATE] and stated family believed his death was a result of poor care by facility staff. Interview on [DATE] at 8:17 A.M., with CNP #500 revealed he had seen the resident on [DATE] for Physician #501 to review admission orders. The CNP reported he had ordered labs on [DATE], however the labs were routine admission lab orders. The CNP reported he had ordered a potassium supplement; however, he did not document or recall if he ordered 10 or 20 mEq of potassium. He stated when he visits the facility, he gives the nurses verbal orders, and the nurses enter the orders in the computer. He had also ordered ted hose to be applied. The CNP reported, in his professional opinion, if a resident had a potassium level of 2.9 (critical) he would have ordered potassium to be administered intravenously and hospitalization for monitoring but ultimately it would be up to the physician to treat. The CNP stated he was not aware or notified the resident had vomiting. The CNP reported he does his own visit dictation from his visits and emails the dictation note to Medical Records Clerk #106 usually the same day or the next day. Interview on [DATE] at 10:30 A.M., with RN #167 confirmed the skilled note dated [DATE] at 4:04 A.M. was not documented with the actual time and date the assessment was completed. The RN reported she had completed the skilled assessment on [DATE] around 11:00 P.M. The RN confirmed the resident was only weighed on admission and stated the resident should have been weighed on [DATE], however there was no documented evidence the weight was obtained. The RN reported staff had documented a weight on [DATE] after the resident had expired in error as well. The RN confirmed the provider was not notified the resident was vomiting due to the family voicing it was normal for the resident to vomit after eating. RN #167 reviewed the resident's May and [DATE] MAR/TAR with the surveyor and confirmed staff were not documenting vomiting or edema on the MAR/TAR as indicated per orders. The RN reported the nurse who received orders on [DATE] from the CNP was an agency nurse and there was no order for a potassium supplement documented in the medical record. The RN confirmed the CNP, and/or physician do not write orders when they see residents and only provide verbal orders for staff to enter. RN #167 confirmed all MAR/TARs were documented on paper and not electronically. Interview on [DATE] at 11:12 A.M., with Physician #501 revealed a resident with a diagnosis of CHF should be weighed daily or at least every other day. The physician confirmed he did not physically see Resident #50 during his brief stay. The physician reported he decided to administer oral potassium because he was unaware the resident had vomiting and thought he could tolerate the oral potassium. The physician reported if he had known the resident was vomiting, he would have sent him to the emergency room for potassium intravenously (IV) and fluids IV. He stated he really can't speak on the matter, it was very unfortunate, and he understood the family concerns however he couldn't really say if the resident's death occurred due to cardiac issues as that was hard to judge. Interview on [DATE] at 1:36 P.M., with RN #180 confirmed there was no documented evidence the facility was monitoring the resident's I&O during his stay. The RN confirmed staff were not documenting on the MAR/TAR the resident was having edema or vomiting as indicated with 0 or + and that signing their initials did not provide information regarding the monitoring. Interview on [DATE] at 9:50 A.M., with Registered Nurse (RN) #180 confirmed the admission orders for the Amiodarone and Mexiletine were not transcribed accurately on admission. RN #180 reported she could not find any evidence a medication error report was completed, or the physician was notified. An additional telephone interview on [DATE] at 8:00 A.M. with FM/POA #502 revealed she was not notified Resident #50's antiarrhythmic medication was not administered as ordered. The POA reported she had issues with Agency LPN #707 not addressing her concerns regarding the potassium supplement timely. The POA stated the LPN kept telling her the resident did not need potassium