**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, document review, and facility policy review, the facility failed to ensure a significant medication error did not occur for 1 (Resident (R)1) of 3 residents reviewed for medication administration. During the 9:00 AM medication pass on 06/05/23, R1 received their own prescribed anti-hypertensive medication (used to treat high blood pressure), a calcium channel blocker (used to treat high blood pressure) and a beta blocker (used to treat high blood pressure and heart failure). During the same medication pass, a different nurse administered R1 antihypertensive and beta blocker medications ordered for a different resident, R6. The administration of the additional medications not ordered for R1 caused the resident's blood pressure to decrease to a level that required medical intervention. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.45 (Pharmacy Services) at a scope and severity of J. On 06/09/23 at 8:28 AM, the Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy situation. The IJ began on 06/05/23 when R1 received another resident's medications, which resulted in a decrease in R1's blood pressure. On 06/09/23 at 8:37 AM, the Administrator was provided with the completed IJ template. The Administrator signed the template and returned the original to the survey team. A Plan of Removal was requested. Findings include: Review of a facility policy titled, Medication Administration, dated 02/16/23, indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. A review of R1's admission Record revealed the facility admitted the resident on 11/08/2018 with diagnoses that included hypertension. Per the record, on 06/08/2022, R1 received a diagnosis of heart failure. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/28/23, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident had moderate cognitive impairment. A review of R1's care plan revised on 03/31/23, indicated R1 had a diagnosis of hypertension. Interventions directed the staff to give anti-hypertensive medications as ordered. A review of R1's care plan revised on 05/30/23, indicated R1 had a diagnosis of congestive heart failure. Interventions directed the staff to give cardiac medications as ordered. A review of R1's Order Summary Report, indicated on 11/19/2022, the resident received an order for amlodipine besylate (a calcium channel blocker) 10 milligram (mg) one tablet by mouth one time a day for essential hypertension, carvedilol (a beta blocker) 3.125 mg one tablet by mouth two times a day for hypertension, clonidine hydrogen chloride (HCl) (an antihypertensive) 0.1 mg one tablet by mouth two times a day for hypertension, and losartan potassium (an antihypertensive) 50 mg one table by mouth two times a day related to acute on chronic diastolic heart failure. Review of R1's Medication Administration Record (MAR), for June 23, revealed during the 9:00 AM medication pass on 06/05/23, Licensed Practical Nurse (LPN) #2 administered the following blood pressure medications to R1: amlodipine besylate 10 mg, carvedilol 3.125 mg, clonidine HCl 0.1 mg, and losartan potassium 50 mg. Per the MAR, R1's blood pressure was recorded as 152/87 millimeters of mercury (mmHg) and pulse (heart rate) as 60 beats per minute (BPM). Review of the Progress Notes, dated 06/05/23 at 9:25 AM, revealed R1 yelled out, I feel dizzy. Per the note, the resident's vital signs were obtained and recorded as a blood pressure of 77/52 mmHg, pulse of 62 BPM, and respirations of 18 breaths per minute. According to the note, the resident was placed in the Trendelenburg position (a position in which a person is laid flat on their back with their feet raised above their head) and the physician was called. Contained within the facility's investigation file was an Employee Statement, signed by LPN2 and dated 06/05/23, which indicated LPN2 administered R1's morning medications according to the physician's orders. Per the statement, LPN2 was called by a certified nursing assistant to R1's room about an hour later. LPN2 indicated the resident stated they felt dizzy. According to the statement, LPN2 notified the supervisor that R1 had received medications from another nurse. Unsuccessful attempts were made to contact LPN2 on 06/08/23 at 12:31 PM, a voice mail message was left. On 06/08/23 at 7:55 PM and 06/09/23 at 2:20 PM, there was no answer. Review of the Medication Error Report Form, dated 06/05/23, revealed on 06/05/23 at 8:38 AM, a nurse administered medications to the wrong resident. The report identified the resident as R1 and the medications as losartan potassium 100 mg and metoprolol succinate extended release (a beta blocker) 25 mg. The report indicated the medication error was discovered on 06/05/23 at 9:25 AM and the contributing factor as the room numbers and names had been temporarily taken off the door due to the wall being painted/wallpaper placed. Interventions/corrective actions implemented by the facility revealed the resident's name and room number were placed on the door and staff education was provided. Review of the Progress Notes, dated 06/05/23 at 10:20 AM, revealed the physician returned the staff's call and gave new orders to start an intravenous (IV) line to administer one liter of ½ normal saline and if unable to start the line, send the resident to the emergency room for evaluation. Per the note, R1 had a blood pressure of 91/46 mmHg, a heart rate of 55 BPM, respirations at 18 breaths per minute, and an oxygen saturation level of 98%. Review of R1's Progress Notes, dated 06/05/23 at 10:25 AM, indicated an unsuccessful attempt to start an IV line. Review of R1's ED [Emergency Department] Provider Notes, dated 06/05/23, revealed R1 presented to the ED with a chief complaint of drug overdose; Per the note, R1 was given the wrong blood pressure medications at the nursing home. Per emergency medical services, R1 received their morning medications to include Norvasc (amlodipine), Coreg (carvedilol) and clonidine and was also administered losartan 100 mg and metoprolol 25 mg that belonged to another resident. Laboratory tests performed were normal and R1 was discharged back to the nursing home with instructions to monitor the resident's blood pressure every four hours and return to the ED if the resident's condition worsened. In an interview on 06/08/23 at 8:05 AM, R1 stated they had an issue a couple of days ago when they received their medications and then someone else gave them more medications that belonged to another resident. Per R1, they had no real problem, the nurses checked them over and they were good now. During an interview with LPN1 on 06/08/23 at 9:11 AM, she stated as she administered medications to residents (on 06/05/23) some of the room numbers and resident names were not on the residents' room doors or walls because of construction. LPN1 acknowledged at approximately 9:00 AM, she administered the medications ordered for R6 to R1. LPN1 stated she thought she had entered R6's room, but she had entered R1's room. LPN1 explained about an hour later after she administered the wrong medications to R1, the resident began to feel dizzy and when the resident's blood pressure was checked, the resident's blood pressure was low. Per LPN1, R1 was placed in the Trendelenburg position, the resident's blood pressure increased, but it decreased again, and the resident was sent to the emergency room (ER). LPN1 stated R1 was okay and returned to the facility later the same day. Review of the Progress Notes, dated 06/05/23 at 9:47 PM, revealed R1 returned to the facility on [DATE] at 8:30 PM. During an interview with the Director of Nursing (DON) on 06/08/23 at 9:21 AM, she stated LPN2 administered R1 their 9:00 AM medications (on 06/05/23) and then LPN1 administered R1 medications that belonged to another resident. According to the DON, the medication error occurred as LPN1 thought she had entered R6's room. In a follow-up interview with the DON on 06/08/23 at 2:20 PM, she stated her expectation was that this incident should never have happened. Per the DON, during orientation the importance of identification of the resident name and the correct medication was reviewed. The DON stated she expected the nurse would have ensured this was the correct resident before the administration of medications. During an interview with the Physician on 06/08/23 at 11:35 AM, he stated he was aware of the incident and ordered intravenous (IV) fluids for R1; however, the facility was unable to get an IV line started so the resident was sent to the hospital for evaluation. The Physician stated the hospital staff called and informed him that the resident's vital signs were normal, the resident experienced no negative outcome, and returned to the facility the same day. The Physician stated the concern regarding this incident would be the resident's decrease in blood pressure. Per the Physician, there was always a concern when the elderly were administered extra medications. During an interview with the Administrator on 06/08/23 at 3:09 PM, she stated R1 stated they felt dizzy, and the facility called the physician. Per the Administrator, LPN1 checked the resident's vital signs, and the resident's blood pressure was low. The Administrator explained the nurse assigned to the resident, LPN2, informed LPN1 that she had already administered R1 their medications. The Administrator stated the resident was immediately placed in the Trendelenburg position and the physician called. The Administrator stated her expectation would be that any nurse who administered medications would verify the right resident and right medication before medication administration. On 06/09/23 at 6:48 PM, a Removal Plan was submitted by the facility and accepted by the State Agency. It read as follows: 1. On 06/09/23 at approximately 8:28 AM, the Facility Administrator and Director of Nursing were notified by the Health Facilities Surveyor of the facility being placed in Immediate Jeopardy (IJ) involving R1. 2. Administrative Team held an ADHOC [a Latin word that meant 'for this situation'] Quality Assurance and Performance Improvement (QAPI) meeting on 06/09/23 at approximately 08:40 AM to discuss the IJ. 3. Attendees were: Administrator, Director of Nursing, Assistant Director of Nursing, North Hall Unit Manager, South Hall Unit Manager, Care Plan Coordinator, Social Service Director, and Medical Director via [by way of] phone. 4. Root cause identified during ADHOC QAPI to be that R1 and R6 Medical Record Photograph is similar in appearance due to R6 having a cap on in [his/her] photograph. The Director of Nursing immediately had the North Hall Unit Secretary retake R6's photograph. 5. Facility respectfully submits the below allegation of compliance for F760 Residents are free of significant medication errors. 6. R1 was affected by deficient practice on 06/05/23 at approximately 9:25 AM. R1 complained of Dizziness and both Licensed Practical Nurse (LPN) assigned to North Hall responded to the resident's room. R1 assigned nurse identified that R1 had received R6 medications. R1 vitals were immediately obtained, R1 was placed in Trendelenburg position, and Primary Physician was notified. New orders obtained to administer intravenous (ID) bolus 0.45% Normal Saline (NS) if able to obtain IV access, and if not to send to the emergency room (ER) for evaluation. 7. All residents who were assigned to North Hall Cart 1 had the potential to be affected. 8. The Director of Nursing provided education to the LPN assigned to North Cart Hall 1 on 06/05/23 on the 7 rights of safe medication administration, the importance of knowing the resident's identification before administering medications and completed a medication administration competency on 06/05/23. 9. All Licensed Nurses present in the facility were provided education on proper medication administration, the 7 Rights of Medical Administration, and the importance of knowing the resident's identification on 06/09/203 by the Nurse Management Team to include the Unit Managers, Assistant Director of Nursing, and Director of Nursing. Remaining Licensed Nurses will be educated by the end of day 06/09/23. Newly Hired Licensed Nurses will be educated during new hire orientation training. New hire skills checkoff will be verified by the Director of Nursing prior to ending orientation training. 10. The Nursing Management Team includes the Unit Managers, Assistant Director of Nursing, and Director of Nursing. The Nurse Management Team conducted a 100 percent audit of all residents Medical Record Photograph on 06/09/23. Photographs that appear blurred or unrecognizable were retaken and uploaded in the medical record on 06/09/23. No photographs will be taken with a hat in place on new admissions. The Nurse Management Team will conduct random medication administration skills check offs for a minimum of 50 percent of scheduled Licensed Nurses weekly x 4 weeks, and monthly x 3. The Director of Nursing will review and report findings during the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. 11. The Administrator is responsible for implementation and oversight of this plan. 12. All Corrections were completed on 06/09/23. 13. All Immediacy of the IJ was removed on 06/09/23. Onsite Verification: Onsite verification was conducted on 06/09/23 to verify the facility had implemented the Removal Plan. The onsite verification revealed the facility had determined the root cause of the medication error, had provided education on the importance of knowing the resident's identification before administration of medications, and completed a medication administration competency check for LPN1 on 06/05/23. On 06/09/23, 100% of all licensed nursing staff were educated on the importance of identifying the seven rights of safe medication administration, to include the right medication administered to the right resident. Licensed staff were interviewed related to the covered in-service material. 100% audits were completed on resident photographs in the electric health record. Photographs that were blurred or unrecognizable were retaken and uploaded into the residents' electronic health record. A medication administration observation was conducted, and no concerns were identified. The IJ continued until 06/09/23 at 8:14 PM, when the survey team verified the elements of the Removal Plan had been implemented. The noncompliance remained on 06/09/23 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy based on the facility continuing training of new hires and on-going audits.