**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, interview and record review, the facility failed to accurately notify the physician of all pertinent information with regards to a significant medication error. Specifically, on [DATE], the facility reported to the Medical Director that Resident (R)1 received twice the dosage of insulin when R1 actually received ten times the dosage of insulin. Furthermore, the facility failed to notify the Medical Director of changes in blood sugar for a two-hour period. On [DATE] at approximately 3:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 6:15 PM, the facility was notified that the failure to accurately notify the physician that Resident (R)1 received 80 units of insulin and the failure to continuously notify the physician of R1's blood sugars after the medication error constituted Immediate Jeopardy (IJ) at F580. The survey team provided the facility with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.10 - Resident Rights. On [DATE] at 10:55 AM, the facility presented an acceptable plan of removal of the IJ. On [DATE] at 12:00 PM, the survey team, validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F580 at a lower scope and severity of D. Findings include: Review of the facility's undated policy titled Acute Condition Changes - Clinical Protocol documented, Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Type 2 diabetes mellitus, malignant neoplasm of head of pancreas, hepatic encephalopathy, and moderate protein-calorie malnutrition. Review of R1's Physician Orders revealed an [DATE] order for Insulin Aspart 100 units/mL qid (four times a day) - before meals and at bedtime. Cover with sliding scale. Give 2 units for 151-200 mg/dL (milligrams per deciliter). Give 4 units for 201 - 250 mg/dL. Give 6 units for 251-300 mg/dL. Give 8 units for 301-350 mg/dL. Give 10 units for 351 mg-400 mg/dL. During an interview on [DATE] at 11:46 AM, Registered Nurse (RN)1 revealed R1 was ordered for 8 units of short acting insulin but received 80. RN1 further stated, Licensed Practical Nurse (LPN)1 used the tuberculin syringe instead of the insulin syringe to calculate the dosage, believing the calibrations to be the same. The resident ate breakfast but not lunch and supper, so the doctor ordered to send the patient out to the hospital. Review of LPN1's statement to the facility, written on [DATE], revealed she took R1's blood sugar at 1:15 PM, which was 343 mg/dL. According to his order, he required 8 units of insulin. She administered the insulin at 1:19 PM. At 1:59 PM she realized she had made a medication error and contacted the Director of Nursing (DON). The DON notified the doctor who ordered blood sugar checks every 30 minutes. If blood sugar is < 80, contact the doctor and administer Glucagon HCl 1 mg/mL. At 2:15 PM the resident's blood sugar was 315 mg/dL. At 2:30 PM, R1 consumed 4 oz of ginger ale. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM, the resident's blood sugar was 163 mg/dL. At 4:45 PM, LPN1 reported the verbal order from the physician to LPN2 during shift change. That evening, around 6:45 PM, LPN1 returned to the facility to finish clerical work. LPN2 informed her she had not taken R1's blood sugars during her shift since it was not in the system. LPN1 took R1's blood sugar which was 49 mg/dL. She notified the physician and injected Glucagon 1 mg/mL. During an interview on [DATE] at 1:34 PM, LPN1 confirmed she administered insulin at 1:19 PM on [DATE] and realized the mistake at 1:59 PM. LPN1 stated she used a tuberculin syringe, not realizing it scaled differently than the insulin syringes. LPN1 stated she realized the mistake at 1:59 PM and notified the Director of Nursing (DON), who notified the physician. The physician gave the verbal order to check blood sugars every 30 minutes and contact her if the blood sugar reached 80 mg/dL and inject Glucagon. LPN1 documented blood sugars on paper and on the Electronic Medical Record (EMR). LPN1 further stated she left her shift at 4:45 PM and relayed the verbal order to the oncoming nurse (LPN2). LPN1 stated she returned to the facility at 6:45 PM and learned that LPN2 had not taken any fingerstick blood sugars in that 2-hour lapse. LPN1 stated she took the blood sugar of R1 and it was 49 mg/dL. LPN1 administered the glucagon. This was the first time that glucagon was administered to R1. During an interview on [DATE] at an unspecified time, the Medical Director (MD) revealed she was contacted by the facility at 2:00 PM on [DATE]. At that time, she was told R1 was given twice the amount of insulin ordered and his blood sugars had been in the 400s prior to administration. The MD stated she was told R1 ate a full lunch and was eating dinner. She did not get phone calls from approximately 5:00 PM to 7:00 PM. The MD further stated at around 7:00 PM she was informed his blood sugar was 90 mg/dL and she instructed the facility to administer glucagon. The MD stated she did not get another call for another few hours when R1's blood sugar dropped to the 70s. The MD had R1 sent out to the hospital. The next day the report was inconsistent with what the MD had been told. R1 had received 80 units of insulin instead of 8 units, and the resident did not eat a full lunch. The MD concluded, had she known this at the time it would have affected her medical decision making. The MD stated she would have ordered R1 to be sent out to the ER immediately rather than conduct 30-minute blood sugar checks. Review of the DON's statement to the facility written on [DATE] at 6:55 PM, revealed that at 2:00 PM she received a text message from LPN1. LPN1 was at the medication cart and informed the DON that R1 had received an overdose of insulin. The DON called the Medical Director who gave telephone orders to check blood sugars every 30 minutes, notify the Medical Director with results, and administer Glucagon HCL 1 mg/mL if blood sugars are below 80 mg/dL. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM his blood sugar was 163 mg/dL. At 6:45 PM, his blood sugar was 49 mg/dL and LPN1 administered the glucagon and notified the physician. The DON instructed LPN1 how to obtain another glucagon emergency kit in case it became necessary to administer a second dose. The Medical Director gave new orders to hold all insulin and check R1's blood sugar in another hour and inform her with results. LPN1 informed LPN2 of the new orders. LPN1 later called the DON to say another glucagon was administered and the Medical Director had been notified. The Medical Director gave new orders to check R1's blood sugars at 11:00 PM and twice during the night. At 11:42 PM, the DON contacted LPN2 for the 11:00 PM blood sugar results - which was 89 mg/dL. The Medical Director was contacted and advised to give R1 orange juice. At 1:50 AM, the DON called LPN2 and she informed the DON that R1 had been sent out to the emergency room. During an interview on [DATE] at 2:30 PM, the DON revealed she was informed of the medication error at 2:00 PM on [DATE]. The DON stated LPN1 told her she had used the tuberculin syringe to administer insulin. The DON used a tuberculin syringe and an insulin syringe to calculate the actual dosage of insulin R1 had received (80 units). The DON then called the physician to tell her what happened. The DON stated she could not remember if she correctly relayed the amount of insulin administered. The doctor gave orders to check blood sugars every 30 minutes and administer glucagon if < 80 mg/dL. The DON further stated she does not remember if this was entered into the electronic medical record (EMR). The DON concluded, it was her expectation that nursing staff alert the physician if there was not necessary equipment for medication administration and for nursing staff to call the physician to clarify any orders they were uncertain of. During an interview on [DATE] at 3:52 PM, LPN2 revealed she did not take R1's blood sugars during her shift. She was only informed by LPN1 during shift change at 4:30 PM and it was not in the EMR. LPN2 stated she did not contact the physician at any point to clarify the verbal order. During an interview on [DATE] at 10:25 AM, the Chief Executive Officer (CEO) revealed he attended a care meeting regarding the incident on [DATE]. At the meeting, it was revealed that the amount of insulin the DON initially reported to the physician was not what had actually been administered. During a follow up interview on [DATE] at 12:33 PM, the MD revealed she received a call from the facility on [DATE]. She was told that R1 was given 40 or 50 units of insulin when he was ordered to receive 8 units and he was eating at that time. The MD stated she considered sending him out, but she decided to have blood sugars taken every 30 minutes and reported to her. The MD stated the facility reported blood sugars timely at first, but from 5:00 PM - 7:00 PM, she didn't receive any notifications. At about 7:00 PM or 7:30 PM, the facility notified her that his blood sugar was 49 mg/dL. The MD told them to administer glucagon. R1's blood sugar rose to 118 mg/dL. This was around 9:15 PM according to her notes, but it might have been earlier. The MD further stated she didn't hear any further notifications until about 11:00 PM when his blood sugar was 89 mg/dL. She asked if they had any more glucagon, and they did not. She asked if the resident was alert enough to drink orange juice, and he was not. The MD then ordered the resident to be sent out to the hospital. The next day, the facility informed her R1 had received 80 units of insulin instead of 40 - 50 units. The MD realized this was why his blood sugar had been so hard to control, and if she had known it was 80 units, she would have sent him to the ER straightaway. During the interview, the MD also revealed that the reason she hadn't received R1 blood sugar notifications from 5:00 PM - 7:00 PM was because LPN2, who came on shift around 5:00 PM, did not follow the verbal order for 30-minute blood sugar checks. It was only when LPN1 returned, that the facility notified her R1's blood sugar was down to 49 mg/dL. The MD stated if LPN1 had not returned, the facility would not have known to administer glucagon. The MD also confirmed that LPN2 did not contact her at any point - either to notify her of R1's blood sugars or to clarify the verbal order for fingerstick blood sugar checks every 30 minutes. On [DATE] at 10:55 AM, the facility presented a removal plan which included: R1 expired at the hospital after re-admission. There were no other residents receiving insulin at time of survey. 1:1 Education provided to LPN1 and the DON who notified the physician of R1's significant medication error using facility policies titled 1. Change in a Resident's Condition or Status and 2. Verbal Orders. Education started on [DATE] to all Licensed Staff related to Facility's policies titled 1. Change in a Resident's Condition or Status and 2. Verbal Orders. Nurses will notify resident's attending physician or the physician on call when there has been a significant change in the resident's physical/emotional/mental condition, need to alter the resident's medical treatment significantly, and need to transfer the resident to hospital/treatment center. Changes in a resident's condition or status will be communicated to on-coming and out-going nurse verbally, in writing, and recorded in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A 24-hour report in paper and 24-hour electronic documentation will be reviewed by [Interdisciplinary Team] IDT every morning during stand-up meeting for compliance and review of implemented interventions. Documentation and Compliance will be presented and reviewed monthly by the QAPI committee to inform process changes and the need for additional staff training, education, and care planning. Performance Improvement Project (PIP) will be updated monthly by IDT when needed related to additional education, training, and care plan updates for specific residents if appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, interview and record review, the facility failed to protect 1 of 4 residents from significant medication errors. Specifically, on [DATE] at 1:19 PM, Licensed Practical Nurse (LPN)1 administered 80 units of insulin to Resident (R)1 when he was supposed to receive 8 units. This failure placed R1 at risk for serious harm and/or death due low blood sugars that could potentially cause seizures, hypoglycemic coma, or death. On [DATE] at approximately 3:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 6:15 PM, the facility was notified that the failure to administer the prescribed dosage of insulin to R1 constituted Immediate Jeopardy (IJ) at F760. The survey team provided the facility with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On [DATE] at 10:55 AM, the facility presented an acceptable plan of removal of the IJ. The survey team, validated the facility's due diligence to correct the noncompliance and is considering this IJ at Past Noncompliance as of [DATE]. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care. Findings include: Review of the facility policy titled Adverse Consequences and Medication Errors last revised on February 2023 revealed that, a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medication errors include giving the wrong dose. A significant medication-related error is defined as requiring hospitalization, requiring treatment with prescription medication, and life-threatening. Review of the facility policy titled Subcutaneous Injections last revised on [DATE] revealed that in preparation for subcutaneous injections, staff must verify the physician's order for the medication (resident's name, drug name, dose, time, and route of administration), review the resident's care plan to assess for any special needs, and assemble the equipment and supplies as needed. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Type 2 diabetes mellitus, malignant neoplasm of head of pancreas, hepatic encephalopathy, and moderate protein-calorie malnutrition. Review of R1's Physician Orders revealed an [DATE] order for Insulin Aspart 100 units/mL qid (four times a day) - before meals and at bedtime. Cover with sliding scale. Give 2 units for 151-200 mg/dL (milligrams per deciliter). Give 4 units for 201 - 250 mg/dL. Give 6 units for 251-300 mg/dL. Give 8 units for 301-350 mg/dL. Give 10 units for 351 mg-400 mg/dL. During an interview on [DATE] at 11:46 AM, Registered Nurse (RN)1 revealed R1 was ordered for 8 units of short acting insulin but received 80. RN1 further stated, Licensed Practical Nurse (LPN)1 used the tuberculin syringe instead of the insulin syringe to calculate the dosage, believing the calibrations to be the same. The resident ate breakfast but not lunch and supper, so the doctor ordered to send the patient out to the hospital. Review of R1's late entry progress note dated [DATE] at 5:20 PM, revealed R1 received an overdose of insulin on [DATE] at 1:19 PM. At 2:00 PM, the facility contacted the Director of Nursing (DON) who contacted the Medical Director. A verbal order was given to check R1's blood sugar every 30 minutes and inject Glucagon HCL 1 mg/mL if blood sugars went below 80 mg/dL. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM, R1's blood sugar was 163 mg/dL. At 6:45 PM, R1's blood sugar was 49 mg/dL. The Medical Director was notified and Glucagon was administered. The Medical Director advised to call back with blood sugar results in 1 hour. At 7:45 PM, R1 opened his eyes when name was called. A sternal rub was performed, and blood sugar was 118 mg/dL. The Medical Director was notified and gave another order for Glucagon administration. The Medical Director gave another verbal order to hold all insulin and check blood sugar levels at 11:00 PM and twice throughout the night. Review of LPN1's statement to the facility, written on [DATE], revealed she took R1's blood sugar at 1:15 PM, which was 343 mg/dL. According to his order, he required 8 units of insulin. She administered the insulin at 1:19 PM. At 1:59 PM she realized she had made a medication error and contacted the Director of Nursing (DON). The DON notified the doctor who ordered blood sugar checks every 30 minutes. If blood sugar is < 80, contact the doctor and administer Glucagon HCl 1 mg/mL. At 2:15 PM the resident's blood sugar was 315 mg/dL. At 2:30 PM, R1 consumed 4 oz of ginger ale. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM, the resident's blood sugar was 163 mg/dL. At 4:45 PM, LPN1 reported the verbal order from the physician to LPN2 during shift change. That evening, around 6:45 PM, LPN1 returned to the facility to finish clerical work. LPN2 informed her she had not taken R1's blood sugars during her shift since it was not in the system. LPN1 took R1's blood sugar which was 49 mg/dL. She notified the physician and injected Glucagon 1 mg/mL. During an interview on [DATE] at 1:34 PM, LPN1 confirmed she administered insulin at 1:19 PM on [DATE] and realized the mistake at 1:59 PM. LPN1 stated she used a tuberculin syringe, not realizing it scaled differently than the insulin syringes. LPN1 stated she realized the mistake at 1:59 PM and notified the Director of Nursing (DON), who notified the physician. The physician gave the verbal order to check blood sugars every 30 minutes and contact her if the blood sugar reached 80 mg/dL and inject Glucagon. LPN1 documented blood sugars on paper and on the Electronic Medical Record (EMR). LPN1 further stated she left her shift at 4:45 PM and relayed the verbal order to the oncoming nurse (LPN2). LPN1 stated she returned to the facility at 6:45 PM and learned that LPN2 had not taken any fingerstick blood sugars in that 2-hour lapse. LPN1 stated she took the blood sugar of R1 and it was 49 mg/dL. LPN1 administered the glucagon. This was the first time that glucagon was administered to R1. During an interview on [DATE] at an unspecified time, the Medical Director (MD) revealed she was contacted by the facility at 2:00 PM on [DATE]. At that time, she was told R1 was given twice the amount of insulin ordered and his blood sugars had been in the 400s prior to administration. She was told he ate a full lunch and was eating dinner. The MD stated she did not get phone calls from approximately 5:00 PM to 7:00 PM. At around 7:00 PM she was informed R1's blood sugar was 90 mg/dL and she instructed the facility to administer glucagon. The MD stated she did not get another call for another few hours when R1's blood sugar dropped to the 70s. The MD stated she had R1 sent out to the hospital. The MD further stated, the next day the report was inconsistent with what she'd been told. R1 had received 80 units of insulin instead of 8 units, and the resident did not eat a full lunch. The MD stated if she had known this at the time it would have affected her medical decision making. She would have ordered R1 to be sent out to the ER immediately rather than conduct 30-minute blood sugar checks. The MD concluded that potential risks for a resident receiving ten times the ordered dosage of insulin included blood sugars dropping and causing seizures, unresponsiveness, hypoglycemic coma, or even death. Review of the DON's statement to the facility written on [DATE] at 6:55 PM, revealed that at 2:00 PM she received a text message from LPN1. LPN1 was at the medication cart and informed the DON that R1 had received an overdose of insulin. The DON called the Medical Director who gave telephone orders to check blood sugars every 30 minutes, notify the Medical Director with results, and administer Glucagon HCL 1 mg/mL if blood sugars are below 80 mg/dL. At 3:00 PM, R1's blood sugar was 275 mg/dL. At 4:43 PM his blood sugar was 163 mg/dL. At 6:45 PM, his blood sugar was 49 mg/dL and LPN1 administered the glucagon and notified the physician. The DON instructed LPN1 how to obtain another glucagon emergency kit in case it became necessary to administer a second dose. The Medical Director gave new orders to hold all insulin and check R1's blood sugar in another hour and inform her with results. LPN1 informed LPN2 of the new orders. LPN1 later called the DON to say another glucagon was administered and the Medical Director had been notified. The Medical Director gave new orders to check R1's blood sugars at 11:00 PM and twice during the night. At 11:42 PM, the DON contacted LPN2 for the 11:00 PM blood sugar results - which was 89 mg/dL. The Medical Director was contacted and advised to give R1 orange juice. At 1:50 AM, the DON called LPN2 and she informed the DON that R1 had been sent out to the emergency room. During an interview on [DATE] at 2:30 PM, the DON revealed she was informed of the medication error at 2:00 PM on [DATE]. The DON stated LPN1 told her she had used the tuberculin syringe to administer insulin. The DON used a tuberculin syringe and an insulin syringe to calculate the actual dosage of insulin R1 had received (80 units). The DON then called the physician to tell her what happened. The DON stated she could not remember if she correctly relayed the amount of insulin administered. The doctor gave orders to check blood sugars every 30 minutes and administer glucagon if < 80 mg/dL. The DON further stated she does not remember if this was entered into the electronic medical record (EMR). The DON concluded, it was her expectation that nursing staff alert the physician if there was not necessary equipment for medication administration and for nursing staff to call the physician to clarify any orders they were uncertain of. During an interview on [DATE] at 10:25 AM, the Chief Executive Officer (CEO) revealed that fundamentally, LPN1 failed to follow the physician order. She used the incorrect syringe to administer the insulin, resulting in administration of the incorrect dosage. During an interview on [DATE] at 12:22 PM, the Pharmacist revealed that an overdose of insulin carries the risk of serious harm or death. On [DATE] at 10:55 AM, the facility presented a removal plan which included: R1 expired at the hospital after re-admission. There were no other residents receiving insulin at time of survey. 1:1 Education provided to LPN1, monitoring of R1's blood sugars, and notification to family. Education started on [DATE] to all Licensed Staff related to Facility's policies of Administering Insulin Medication. The facility obtained skill validations and return demonstrations for all Licensed Staff how to administer Insulin per policy and Safety. All tuberculin syringes were removed from the medication cart and moved to the medication room. Insulin syringes remain available on the medication cart. Random skill validation and demonstrations of Insulin Administration among Licensed Staff will occur 2 times weekly x 6 weeks. Documentation Errors / Compliance are documented, reported, and reviewed monthly by the QAPI committee to inform process changes and the need for additional staff training. Performance Improvement Project (PIP) will be updated monthly in terms of additional education of nurses, skill validation and care plan updates for specific residents receiving insulin treatment.