**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective 02/21/23 related to the facility's failure to ensure a resident was administered medication as ordered in the discharge instructions. The facility failed to ensure Plavix and Aspirin were not continued upon admission when the Resident had a diagnosis of traumatic subdural hematoma. (A serious condition where blood collects between the skull and the surface of the brain.) Resident #1's CT scan of the head, dated 03/04/23 documented the resident's subdural hematoma had increased in size and had an increased right to left midline shift which measured 1.4 cm. (A displacement of brain tissue across the center line of the brain.) On 03/21/23,the Oklahoma State Department of Health verified the existence of the past noncompliance IJ related to the facility's failure to ensure medications were administered as ordered to prevent worsening of a subdural hematoma. The past noncompliance IJ was removed effective 03/07/23 after the facility put measures in place to prevent recurrence. On 03/07/23 a QAPI meeting was conducted, leadership was educated by the Director of Clinical Operations on the policies and procedures for completion of medication reconciliation upon admission, physician order entry and transcription, admission review, and event investigation including timely reporting. Staff were inserviced about the policy and procedures for admissions, medication reconciliation, adverse effects and medication errors, and event reporting on 03/07/23 or prior to their next scheduled shift. The facility performed medication reconciliation for current residents who were admitted in the last 30 days. The IDT reviewed new admission daily during the clinical meeting. The facility put the following action plan in place to prevent recurrence: Action plan Going Forward .Residents newly admitted to the community will have a medication reconciliation opened and will be reviewed by the Interdisciplinary Team during daily clinical huddle and will audit all new admissions within 24 hours of admission to assure DC orders coincide with our MAR. The Interdisciplinary Team will always review all new admissions .on a weekly basis .If a resident comes over from Assisted Living or Memory Care all orders are to be discontinued and re-entered per DC orders from hospital stay. Any discrepancies found upon admission will require clarification from the doctor that provided care or primary care provider . On 03/21/23 CMAs and Nursing staff were interviewed and verified they had received the in-service relating to medication error. Nurses verified they knew how to perform medication reconciliation with new admissions and readmissions and what the process was if they found a discrepancy. The audits for medication reconciliation were reviewed. Based on record review and interview, the facility failed to ensure discharge instructions for medication administration was followed for one (#1) of three sampled residents who were admitted or readmitted to the facility in the past 6 months. The Resident Census and Conditions of Residents report, dated 03/17/23 documented 54 residents resided in the facility. Findings: A facility policy titled Reconciliation of Medication of Admission, dated 12/2017, read in parts, .The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications .upon admission or readmission to the community .Gather the information needed to reconcile the medication list .Approved medication reconciliation form .Discharge summary from referring community .admission order sheet .All prescription medication and supplement information obtained from the resident/family during the medication history .Most recent medication administration record .if this is a readmission .Medication reconciliation helps to ensure that all medications .on the list are appropriate for the resident and his/her condition .Review the list carefully to determine if there are discrepancies/conflicts .If there is a discrepancy .Contact the resident's primary physician in the community .Document findings and actions .Contact the attending physician to verify the orders . Resident #1 was admitted to the facility on [DATE] from the hospital with diagnoses which included dehydration and subdural hematoma. A hospital Discharge summary, dated [DATE] read in parts, .Hospitalization Diagnoses .DATES OF HOSPITALIZATION 02/16/23 discharge date [DATE] .Admit DX/Problem List .Dehydration .Subdural hematoma .Discharge Medication List .Continue taking these medications: Benzonatate Cap .100 MG .BY MOUTH TWICE DAILY AS NEEDED .for COUGH . Loratadine .10 MG TAB BY MOUTH DAILY . levETIRAcetam .Tab 250 MG .TWICE DAILY . Acetaminophen Tab .325 MG .TWICE DAILY . Midodrine 10 MG .DAILY . Acetaminophen .325 MG .1-2 TABLET .EVERY 4 HOURS AS NEEDED for temp GREATER THAN 100.4 . Omeprazole .20 MG .DAILY . LEVOTHYROXINE SODIUM .100MCG DAILY Guaifenesin-Codeine Liquid .5 MILLILITER .EVERY 4 HOURS AS NEEDED . for COUGH . Magnesium Hydroxide Liquid 400 MG/5ML .DAILY AS NEEDED for CONSTIPATION Physician's orders, dated 02/21/23, documented the following medications were in Resident #1's electronic record for administration and not documented to be continued on the hospital discharge orders: Plavix 75 mg daily for TIA prevention with an original order date of 12/30/19 and Aspirin 81 mg delayed release tablet for platelet aggregation with an original order date of 02/18/21. Plavix is a drug that inhibits the ability of platelets to clump together. Plavix prevents blood clots. Plavix could make the blood thinner and increase the risk of brain hemorrhage. A MAR, dated 02/21/23 through 02/28/23, documented the Plavix 75 mg and Aspirin 81 mg were administered without a physician's order on 02/22/23, 02/23/23, 02/25/23, 02/26/23, and 02/28/23. A MAR, dated 03/01/23 through 03/31/23, documented Plavix 75 mg and Aspiring 81 mg were administered without a physician's order on 03/01/23 03/03/23, and 03/04/23. A nurse's progress note, dated 02/26/23, read in parts, .Patient continues on SNF for trauma subdural hemorrhage. She is alert and oriented x2. Patient is able to voice needs .She is mobile via wheelchair. Patient requires moderate assistance with ADL's . A nurse's note, dated 02/28/23, read in parts, .Resident has been weak and having difficulty working with therapies and difficult to stand for transfers. Resident is confused x3 for the past 2 days. Called [primary care physician] and received order for UA obtained via straight cath and send to C&S if indicated Urine is dark and amber and with a lot of sediment .Resident had to have someone feed her . A nurse's note, dated 03/03/23, read in parts, .[primary care physician] in facility to see resident. Gave this nurse new orders .discontinue ASA and Plavix due to recent brain bleed. MAR updated .LPN notified of new orders. Aspirin and Plavix removed from cart . Resident #1 received the Plavix and Aspirin eight times after admission without a physician's order. A physician's order, dated 03/03/23, documented to discontinue the Plavix and Aspirin. A physician's progress note, dated 03/03/23, read in parts, .chart and medications have been reviewed .recently in the hospital after a fall with hitting her head and brain bleed .Current Medications Milk of Magnesia .Tylenol .Levsin .Midodrine .Omeprazole .Levothyroxine .Keppra Claritan .Medical History .atrial fibrillation hypertension .She is lethargic Plan .D/C Plavix and Aspirin .Changed/Discontinued Medication(s) .Discontinued By Other MD: ASPIRIN 81 MG TABLET .Discontinued By Other MD: PLAVIX 75 MG TABLET . A nurse's note, dated 03/04/23 at 12:48 p.m., read in parts, .Resident had a decline in health since this AM. Aides came to nurse reporting that resident was not responding to commands. This nurse walked in and tried verbal and minimal painful stimuli. Resident opened eyes briefly and then rolled them back. This nurse attempted to call [primary care physician] for orders to send out with no return phone call. This nurse called [medical director] and he gave approval to send out only if I had attempted [primary care physician] .This nurse called [ambulance service] to send out to ER . An ED Physician Documentation Note, dated 03/04/23, read in parts, .presents to ED via [ambulance service]-Ground with complaints of S/S of Possible Stroke .The symptoms/episode began/occurred last month. Associated signs and symptoms .This patient did not experience any loss of consciousness .The patient has experienced a previous episode, last month .seen here last month, dx with brain bleed. [Physician] has already called telling me the bleed is worse and there is 1.4 cm midline shift .Symptoms have worsened .Diagnosis Traumatic subarachnoid hemorrhage .Nontraumatic subarachnoid hemorrhage, unspecified .Hospice set up by nursing home/nurse . A nurse's progress note, dated 03/13/23 at 3:15 p.m., read in parts, . The DPOA was notified of resident was on Plavix and aspirin for 8 days, but was discontinued from hospital . On 03/17/23 at 12:28 p.m., the DON stated Resident #1 was admitted to the facility after having a fall in the facility's assisted living center which resulted in a subdural hematoma. The DON stated Resident #1 was not supposed to have continued their Aspirin and Plavix when they were admitted to the skilled nursing facility on [DATE]. The DON stated they identified the medication error 10 days later. The DON stated on 03/03/23 the resident's primary care physician saw the resident and discontinued the Aspirin and Plavix. They stated the resident was sent to the hospital on [DATE]. The DON stated they had a QAPI meeting on 03/07/23 and put measures in place to prevent the recurrence. They stated Resident #1 was now on hospice. They stated the medical director had seen the resident on 02/23/23 and knew the resident was on Plavix and Aspirin. The DON was asked if the medical director had been notified on 02/23/23 the Aspirin and Plavix were discontinued at the hospital. They stated they would have to ask the medical director. On 03/17/23 at 3:11 p.m., LPN #3 stated Resident #1 arrived at facility and their orders were in the computer before they had arrived to work on 02/21/23. The LPN was asked if they had reconciled the medications for Resident #1 when they were admitted to the facility. They stated they clicked the No Discrepancy button but did not reconcile the medications. They stated they did not know how to do it until they had the inservice. The LPN was asked if they reviewed the medications ordered in the computer with the discharge medication list. They stated, No. On 03/17/23 at 3:56 p.m., the DON stated the order for the Aspirin and Plavix were in the computer system because Resident #1 lived in the assisted living prior to going to the hospital. The DON was asked if Resident #1's primary care physician had been notified of the discrepancy in the hospital discharge orders. They stated, Not to my knowledge. The DON stated they should have reviewed the medications in computer against the discharge orders and notified Resident #1's primary care physician. On 03/17/23 at 4:29 p.m., the medical director was asked if they were aware the hospital had discontinued Resident #1's Aspirin and Plavix prior to admission to the facility. They stated they could not recall. The medical director stated Resident #1 was not their patient and Resident #1's primary care physician was adamant they would handle their patients. The medical director was asked if they would have continued Aspirin and Plavix if a patient had a subdural hematoma. They stated it would be a case by case basis and they would have to consider the risks and benefits. They stated they would probably hold off until the subdural hematoma had healed a bit. On 03/21/23 at 10:55 a.m., the MDS coordinator stated they had received a fax from the hospital with Resident #1's discharge orders. They stated they put them in the computer. The MDS coordinator was asked if they had put in the Aspirin or Plavix. They stated no, the medications were in the computer because the resident had lived in the assisted living prior to going to the hospital. They stated they thought they had marked discontinue in the computer for the Aspirin and Plavix. The MDS coordinator stated the charge nurse who admitted the resident was responsible for reviewing the discharge paper work and the physician's orders. The MDS coordinator stated on 03/03/23, Resident #1's primary care physician had asked them if the resident was on Aspirin and Plavix and asked them to discontinue the medications.