**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 residents (Resident #67) reviewed for enteral feeding. 1. RN G failed to contact the physician and obtain orders before using a de-clogger (a device designed to clear obstructed feeding tubes) to unclog Resident #67's g-tube (Gastrostomy tube, tube inserted through the belly that brings nutrition directly to the stomach) on [DATE]. The facility had de-clogger tools onsite, even though they did not train nurses on their use, and it was not an approved method for de-clogging a g-tube. 2. The facility failed to follow physician orders for Resident 67's enteral feeding tube to be flushed with 100 ml of water every 2 hours. An Immediate Jeopardy was identified on [DATE] at 8:42 AM. The IJ template was provided to the facility on [DATE] at 9:00 AM. While the Immediate Jeopardy was removed on [DATE] at 3:30 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a severity level of immediate threat, due to the facility's continuation of in-servicing and monitoring the plan of removal. This failure placed residents at risk for serious injury and serious harm such as injury to the gastrointestinal tract such as ulceration, bleeding, and perforation. Findings included: 1. Record review of Resident #67's admission Record dated [DATE] reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #67's quarterly MDS assessment dated [DATE] reflected his diagnoses included cerebral artery (supplies blood to the brain), aphasia (language disorder) following cerebral infarction (stroke), tracheostomy status (procedure to help air and oxygen reach the lungs), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphasia (swallowing difficulties) following cerebral infarction, respiratory failure, and renal failure. Resident #67's BIMS score was not complete. The MDS further revealed Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube. Record review of Resident #67's care plan revised date [DATE] reflected: Feeding Tube: Resident requires the use of a feeding tube and is at risk for aspirations, weight loss, and dehydration. Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable, no signs or symptoms of malnutrition, or dehydration through review date. Interventions: Administer tube feeding and water flushes as ordered. Record review of Resident #67's physician orders dated [DATE] reflected an order for Enteral Feed Order every shift Intermittent Pump Enteral Feeding: Formula Glucerna 1.5 Amount: Rate: 65 cc Frequency: Total mls/22 hours. Record review of Resident #67's physician orders dated [DATE] reflected an order for Enteral Feed Order every 4 hours flush 200 mls of water to run concurrently with enteral feeding. D/C Date - [DATE]. Record review of Resident #67's physician orders dated [DATE] reflected an order for Enteral Feed Order every 2 hours flush 100 mls of water to run concurrently with enteral feeding. Observation on [DATE] at 11:02 AM revealed Resident #67 lying in bed. He could not answer questions. Resident #67 was connected to his feeding pump, and the feeding rate was set at 65 mL/hr. and the water flush rate was set at 200 mL every 4 hours. The formula bag was dated [DATE] at a rate 65 mL/hr. The water bag was dated [DATE]. Observation on [DATE] at 9:30 AM revealed Resident #67 lying in bed with his feeding pump connected. The feeding rate was set at 65 mL per hour, and the water flush rate was set at 200 mL every 4 hours. Interview on [DATE] at 1:32 PM with RN F revealed she was the nurse assigned to Resident #67. RN F stated Resident #67 had a g-tube, she stated the night shift placed a new formula and water bag. RN F reviewed Resident #67's physician orders and stated the resident had an order to flush 100 mls of water every 2 hours. Observed RN F entered Resident #67's room and observed the resident's feeding pump. She stated the feeding pump rate was incorrect, it was set at 200 mls of water every 4 hours. Observed RN F adjust the feeding pump to 100 ml of water flush every 2 hours. She stated when she came in for her shift (6 AM -2 PM) she completed her rounds and checked on residents feeding pumps. RN F stated she might have missed it. She stated the potential risk of not providing Resident #67 with the correct timed flushes could lead to the g-tube clogging. Interview on [DATE] at 2:29 PM ADON B stated Resident #67's water flushes were changed from 200 ml every 4 hours to 100 mls every 2 hours in the month of [DATE]. She stated she was made aware Resident #67's feeding pump was not accurate; however, there were times that Resident #67's FM had concerns regarding the amount of water the resident received. She stated water flushes were changed upon Resident #67's family member request. She stated Resident #67's family member had been educated on why that amount of water was given to the resident. She stated it was believed Resident #67's FM might have changed the water flushes amount. However, it was expected for the nurses to follow physician orders and if the family did not agree, the nurses should notify the doctor and obtain orders. She stated the potential risk would be the g-tube clogging. Interview on [DATE] at 11:37 AM with NP revealed Resident #67 had issues with g-tube clogging. She stated she was aware of Resident #67's water flushing orders. She stated the orders were changed back in [DATE] to increase the frequency of the water flushes to prevent the g-tube to clog. She stated she was unaware that the resident was receiving water flushes every 4 hours. She stated the water flushes were changed to every 2 hours specifically to prevent the g-tube to clog. She stated her expectations were for the nurses to follow physician orders. She stated the potential risk would be the g-tube to clog. Interview on [DATE] at 2:25 PM with RNC revealed her expectations were for the nurses to follow physician orders regarding water flushes. She stated she was unaware Resident #67 had any issues with his g-tube clogging. She stated water flushes were needed to prevent the g-tube from clogging. 2. Record review of Resident #67's progress notes dated [DATE] at 06:31 AM by RN G reflected Unable to administer AM medications due g-tube being clogged. Multiple attempts made by x 3 nurses to unclog g-tube. De-clogger tool and coke used. Attempts were unsuccessful. Physician contacted awaiting response. [FM] is aware and present at the bedside. Record review of Resident #67's progress notes dated [DATE] at 09:50 by RN F reflected The night nurse reported that the patient's g-tube is clogged, initial attempt to unclog the tube was unsuccessful, NP was notified. Order received from NP to try to unclog it first with [Don], if unsuccessful then send pt to ER. The [Don] was notified and assisted in successfully unclogging the tube. Bowel sounds were present, and the patient had a bowel moment this morning. NP was notified, got an order to resume his feeding. Observation and interview on [DATE] at 9:30 AM revealed Resident #67 lying in bed with his feeding pump connected and he had a trach. Resident #67's family member was in the room visiting, she stated she had no concerns regarding the care the resident was receiving at the facility. Resident #67's family member stated in [DATE] unknown of the exact dates, the resident was having issues with his g-tube clogging. She stated she could not recall much of the events; however, the facility staff made several attempts to unclog the g-tube and when unsuccessful the resident was transported to the hospital. She stated she recalled the nurses using a de-clogger but did not recall much of what happened or how it was used. Interview on [DATE] at 2:22 PM with RN F stated in the month of [DATE], Resident #67 had issues with g-tube clogging. She stated she could not recall the exact dates; however, one morning she arrived for her 6 AM-2 PM shift and the night nurse informed her that Resident #67's g-tube was clogged, and she could not provide him with his medications. She stated she was unsure if a de-clogger was used. She stated if a nurse used a de-clogger, the nurse must obtain a physician order. She stated she was unsure if a physician order was obtained. Interview on [DATE] at 2:29 PM with ADON A stated Resident #67 had his g-tube replaced once since being admitted to the facility. She stated since Resident #67's g-tube had been changed there had not been any issues. She stated when a g-tube clogs the nurses use methods like pulling back residual, use warm water, cranberry juice, or use coke to break it down. She stated it was up to the nurse's discretion on what method to use and if nothing was successful the resident should go to the hospital. She stated de-cloggers should not be used because it was not part of their training and was unaware if any de-clogger had been used. She stated she was unsure if they had any de-clogger tool in the facility. However, if a nurse knows how to use a de-clogger and felt comfortable using that method it would be up to the nurse's judgment. She stated nurses should obtain physician orders before using a de-clogger. Observation on [DATE] at 4:07 PM with Central Supply Tech of supply room located in the North Station revealed one 16 Fr. 39.5 cm de-clogger tool and on the South Station supply room revealed four 16 Fr. 39.5cm de-clogger tool. Central Supply Tech stated she was unsure why the facility had de-cloggers. She stated she just orders them, she stated she was not a nurse and was unsure why the de-cloggers were used for. Interview on [DATE] at 4:21 PM with RN J stated he had worked with Resident #67 before; he stated he had not had any issues with Resident #67's g-tube clogging. He stated a couple of weeks ago, unknown of the exact date, Resident #67's g-tube clogged. He stated he went to Resident #67's room to assist and help unclog the g-tube. He stated they tried different methods and a de-clogger was used. Then stated he was unsure if a de-clogger was used and was unsure if the nurse was able to unclog the g-tube. RN J stated he could not recall the nurses who were assigned to Resident #67 and was unsure if the physician was notified. RN J stated he had not used a de-clogger before and had not been in-serviced on how to use one. Interview by phone on [DATE] at 8:08 AM with the Medical Director revealed he was aware of Resident #67's g-tube having multiple issues with clogging. The Medical Director stated each facility used different methods to unclog a g-tube. He stated he did not recall any staff notifying him or him giving any orders for the use of a de-clogger. He stated he was not sure what a de-clogger was. The Medical Director stated if the facility nurses had proper training on how to use a de-clogger and if the tool/device was FDA approved he did not have any issues with the nurses using it. He stated he was not familiar with the device to know of any possible risk, he stated there could be risk, but he did not know what the probability of it would be. The Medical Director stated the use of coke had been used at hospitals in the ERs because the carbonation helped with unclogging g-tubes. He stated he had no issues with nurses using that method. The Medical Director stated he did not necessarily need to be called all the time when situations happened. Interview on [DATE] at 8:52 AM with ADON B revealed when a resident's g-tube clogs it was the expectation for the nurse to notify the doctor, attempt to unclog it by using methods like flushing with warm water, milk it down (hold the tube on the top and push down), and if nothing was working send the resident out to the emergency room. She stated they have used a de-clogger in the past usually after talking to the doctor if they cannot clear the line. She stated on her station they have not used any de-cloggers and was unaware if de-cloggers had been used in the South station. She stated it was up to the doctor's discretion if de-cloggers were to be used. She stated if a de-clogger was used it should be documented and had obtained a physician order. She stated a de-clogger was not part of their training and not part of the nurses check off. Interview on [DATE] at 11:37 AM with NP revealed Resident #67 had issues with his g-tube clogging. She stated it was not normal for his g-tube to clog. She stated in [DATE], unknown of exact date, the resident was sent out to the ER twice. The first time was because the g-tube was partially dislodged. She stated the hospital should have changed the g-tube bud did not. She stated the resident returned to the facility and the g-tube clogged. She stated she was notified, and she recommended to try to unclog it first in house and if unsuccessful send the resident to the hospital; however, the nurse was able to successfully unclog the g-tube. She stated she was unaware a de-clogger and coke was used. She stated her expectations were for the nurses to use methods like using a 10 ml syringe to push back pressure, or to use water. She stated she would not recommend using a de-clogger and had never been a point in time where they would use a de-clogger. She stated maybe there was a misunderstanding when she said de-clog in house that maybe the nurses thought to use any method to unclog it. The NP stated the risk of using a de-clogger could cause injury or if the de-clogger was long enough to perforate something. She stated nurses should be trained to use a de-clogger and should obtain orders if a de-clogger was being used. The NP stated, unknown of the exact date, Resident #67 went to the hospital again because his g-tube clogged again, his g-tube was changed, and it had been working fine since then. Interview on [DATE] at 1:26 PM with RN G stated in [DATE], unknown of the exact date, she was going to give Resident #67's morning medications; however, the g-tube was clogged. She stated she tried to flush it with warm water to try to de-clog it but did not work, she then used a de-clogger and it was effective. She stated RN F was in the room present and tried to assist with unclogging the g-tube. She stated she was the one who used the de-clogger to unclog the g-tube. She stated she did not contact the physician and did not obtain orders prior to using the de-clogger. She stated she was unsure if the other nurses present contacted the doctor or NP. She stated she had used a de-clogger in the hospital setting, was comfortable using a de-clogger and she knew how to use it. She stated it was the first time using a de-clogger at the facility. She stated she should have contacted the doctor first and obtained orders before using a de-clogger. She stated the risk of using a de-clogger would be puncturing the tube if not careful or harming the tube more itself. Interview on [DATE] at 2:25 PM with RNC revealed her expectation for when a g-tube clogs was the nurses were expected to follow policy and procedure for g-tube care. If there were any issues, the nurses should contact the doctor and obtain orders. She stated the nurses should not be using a de-clogger because the facility did not have any policy for a de-clogger, and they could not ensure the nurses had been trained on how to use one. She stated she was unsure why the facility had any de-cloggers in the facility. She stated the only policy the facility had if any complications occur the nurses, were to notify the physician or any abnormalities. Record review of the facility's Following Physician Orders policy, dated [DATE] reflected the following: The policy provide guidance on receiving and following physician orders. . For consulting physician/practitioner orders received via telephone, the nurse will: a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order. b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record. c. Carry out and implement physician orders. Record review of the facility's Clinical Practice Guideline: Care of Tube Feed Resident policy, review date [DATE] reflected the following: Resident will remain free of complications related to use of a feeding tube. Tube feeding care should be consistent with the current standards of practice and overall therapeutic goals of the resident and delivered in an ethical manner. Prevention of gastrointestinal complications: Provide formula at prescribed rate using appropriate delivery method . Notify physician of any abnormalities. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 8:30 AM. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 9:00 AM. The facility's Plan of Removal was accepted on [DATE] at 2:15 PM XXX[DATE] @ 8:42 Immediate Jeopardy Called F-693 The facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feedings. IJ F693 Plan of Removal Immediate Actions taken I. Resident specific On [DATE] resident was immediately assessed BY ADON head to toe without any noted signs or symptoms of injury. On [DATE] the 2 other g-tube residents with g-tubes were immediately assessed By ADON LVN head to toe without any noted signs or symptoms of injury. II. System changes On [DATE] all g-tube de-clogger devices were immediate removed from the facility at the time they were identified during the annual survey as this is not part of our policy. On [DATE] all g-tube de-cloggers were brought to the DON office by Central supply for immediate destruction. On [DATE] Central supply and ADON's were immediately instructed to not order any g-tube de-cloggers moving forward no matter who requested them. And to notify the Administrator if asked. On [DATE] Director of Nurses was terminated for failure to participate in this investigation. On [DATE] Facility policy was updated by VP of clinical services to include problem solving to prevent g-tube clogging. III. Education On [DATE] all licensed nurses were immediately in-serviced by ADON on the facility policy is not to use g-tube de-cloggers and on the facility policy on care of the tube fed resident (prevention of gastrointestinal complications, prevention of mechanical complications, prevention of dignity issues, observations and reporting) On [DATE] all licensed nurses were immediately in-serviced by ADON on following physicians orders for administering flushes. This in-service included validating the pump was programmed to match the physician's order at the beginning of their shift. On [DATE] all nurses were in-serviced by ADON on the updated facility policy for care of the tube fed resident (which includes the notification of the physician anytime a g-tube is clogged). All staff that did not attend the in-service's will be in-serviced on all education completed by ADON prior to their next scheduled shift. IV. Monitoring Nursing supply orders will be pulled weekly x 1 month to ensure de-cloggers are not being ordered. DON/Designee will do random checks weekly x 4 weeks to ensure auto flush pumps are programmed to match the flush ordered by the physician. DON and Administrator will review nursing orders monthly at the facility QAPI meeting to ensure continued compliance. Monitoring of the Immediate Jeopardy continued: Record review on [DATE] at 9:20 AM of Resident #67's MAR indicated he had no medications via g-tube scheduled until bedtime. Interview on [DATE] at 9:25 AM a family member of Resident #67 was bedside, the family member stated they were bedside the majority of the day. The family member described how the nurse administers the resident's medications via the g-tube. They described the medications being in separate cups, the nurse administers one cup at a time followed by some water. The medications were allowed to go in on their own, they never used the syringe to force the medications in. Observation on [DATE] at 9:25 AM of Resident #67's feeding pump indicated he was receiving Glucerna at 65 ml/hr and a 100 ml water flush was scheduled every two hours. Record review on [DATE] at 9:30 AM of Resident #67's nursing notes indicated no issues with his g-tube clogging since [DATE]. Record review on [DATE] at 9:50 AM of Resident #70's MAR reflected she was not scheduled to receive any medications via g-tube until the next morning. Record review on [DATE] at 9:53 AM of Resident #70's nursing notes reflected there had been no issues with her g-tube clogging since [DATE]. Observation on [DATE] at 9:55 AM of Resident #70's feeding pump reflected her Glucerna was infusing at 50 ml/hr and a 125 ml water flush was scheduled every 4 hours. Record review on [DATE] at 10:00 AM of Resident #58's MAR revealed she was not scheduled to receive any medications via her g-tube until bedtime. Record review on [DATE] at 10:03 AM of Resident #58's nursing notes reflected there were no issues with her g-tube clogging since [DATE]. Observation on [DATE] at 10:05 AM of Resident #58's feeding pump reflected she was receiving Glucerna at 55 ml/hr with a 75 ml water flush every four hours. Attempts to interview RN G were made via phone on [DATE] at 11:10 AM and 1:40 PM in an attempt to what size and length of de-clogger to use on Resident #67's g-tube. Interview on [DATE] at 11:20 AM with the ADON revealed she did not know how long de-cloggers had been in the facility, they were just always here. Interview on [DATE] at 11:33 AM with the Central Supply Tech revealed she had been in the position since around [DATE] and the de-cloggers were in stock at that time. Several were expired so she ordered more to replace them. The last time she ordered a de-clogger was on [DATE]. She stated on [DATE] all the de-cloggers were turned over to the Administrator. She was advised not to re-order them and to notify the DON if she was asked by anyone to order one. Interview on [DATE] at 11:40 AM with the RNC revealed the previous DON had refused to assist the investigation into de-clogger use, so she was termed. The RNC stated as far as she could determine the previous DON had ordered them to be kept on hand. The DON had stated she trained staff on the use of de-cloggers, but the RNC was unable to locate any training material, no in-services, or anything to indicate de-clogging training had been done with staff. The RNC stated on [DATE] all nursing staff were in-serviced by herself and the ADONs that de-cloggers were not to be used on clogged g-tubes. The nurse was to contact the physician for orders to send the resident to the hospital to have the g-tube replaced or de-clogged. Interview on [DATE] at 12:22 PM with LVN K revealed she had been in-serviced by the ADON on g-tubes. She stated she was not allowed to use the de-clogger, but she had never used one before. She stated she was to call the physician for orders to send the resident to the hospital. If the physician ordered it, they could try to milk or massage the tube to unclog it. Interview on [DATE] at 12:25 PM with LVN H revealed she had been recently in-serviced on g-tubes. She was to call the physician for orders to send them to the hospital. The physician could order them to attempt to unclog the tube by massaging or milking the tube. If the interventions were unsuccessful the resident was to go to the hospital. Interview on [DATE] at 12:30 PM with RN F revealed she had recently been in-serviced on g-tubes. If the resident's g-tube was clogged they were not to use the de-clogger, they were to call the physician for orders to send the resident to the hospital. The physician could order them to attempt to unclog the tube using water on the pump like a bolus or massaging it. Interview on [DATE] at 12:39 PM with LVN L revealed she had been in-serviced on g-tubes recently. She stated it was made clear that de-cloggers were not to be used, and they had been removed from the facility. They were to call the physician for orders to send the resident to the hospital for replacement of the g-tube. Interview on [DATE] at 1:55 PM with RN-J revealed he had been in-serviced on g-tubes. He stated if the tube was clogged, he was to call the physician for orders to send them to the hospital, or to try massaging the tube to unclog it. Phone interview on [DATE] at 2:00 PM with LVN M revealed she had been in-serviced on g-tubes. She stated it was made clear that de-cloggers were not allowed to be used, and they had been removed from the facility. She stated she had never used a de-clogger and had never been trained on them. She stated she was to call the physician for orders. Interview on [DATE] at 2:24 PM with RN N revealed she had been in-serviced on g-tubes recently. She stated de-cloggers had been removed from the facility. She stated she had used the de-clogger in the past, but she had not been trained at this facility. She stated she knew how to use them from past experience. She stated she was now supposed to call the physician for orders to send the resident to the hospital. Interview on [DATE] at 2:28 PM with LVN O revealed he had been in-serviced on g-tubes recently. He stated if the tube is clogged, he can try to massage it first, and if that didn't work he would call the physician for orders to send the resident out. Telephone interview on [DATE] at 3:10 PM with RN Q revealed she had been in-serviced on g-tubes. She stated if the tube was clogged, she was to call the physician for orders. The physician could order the resident sent out, or to try milking the tube before sending the resident out. She stated de-cloggers were not to be used. Record review of the facility's monitoring tool Weekly Monitoring of G-tube Flush reflected it had been completed weekly since [DATE]. Record review of the facility's Ad Hoc QAA meeting, held on [DATE], reflected physician orders, g-tubes orders had been reviewed. Discussion of g-tube de-clogging process was held. All de-clogging tools were removed, and all nurses were to be educated on the new process. An Immediate Jeopardy was identified on [DATE] at 8:42 AM. While the Immediate Jeopardy was removed on [DATE] at 3:30 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses had the appropriate competencies and skills sets to provide nursing services to care for residents' needs and ensure resident safety, in accordance with professional standards of practice necessary for 1 of 5 residents (Resident #1) reviewed for nursing competencies. The facility failed to ensure LVN C was competent in medication administration when LVN C failed to ensure Resident #1 was administered nitroglycerin (medication used to prevent or relieve chest pain caused by coronary artery disease by relaxing blood vessels), as ordered by the physician on 02/04/24. LVN C dispensed an entire bottle of nitroglycerin, which consisted of 25 (0.4 mg) tablets, to Resident #1 when the physician order was for 1 (0.4 mg) tablet resulting in Resident #1 being sent to the emergency room. Resident #1's initial blood pressure at the ER was 86/42. The noncompliance was identified as PNC. The IJ began on 02/04/24 and ended on 02/05/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk to medication administration errors, not receiving the intended therapeutic effects of the medications, and could contribute to adverse reactions resulting in a decline in health, hospitalization, or death. The findings included: A record review of the American Heart Associations' guidance on Understanding Blood Pressure Readings, last reviewed on 05/30/23, reflected a normal blood pressure reading would be 120/80. Accessed on 02/16/24 from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings A record review of Resident #1's electronic Face Sheet dated 02/06/24 reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses that included need for assistance with personal care, muscle weakness, unsteadiness on feet, and atherosclerotic heart disease of native coronary artery (caused by plaque buildup in the wall of the arteries that supply blood to the heart). A record review of Resident #1's Optional State Assessment MDS, dated [DATE] indicated Resident #1 had a BIMS score of 11, which indicated the resident's cognition was moderately impaired. A record review of Resident #1's Physician Orders, dated 02/04/24, reflected Nitroglycerin Sublingual Tablet 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for chest pain x 3 does, if no relief call MD, send to ER for further Evaluation. A record review of Resident #1's Care Plan, dated 09/08/22, indicated a focus area of has altered cardiovascular (relating to the heart and blood vessels) status r/t ASHD/CAD and the interventions included .Monitor for complaint of chest pain. Enforce the need to call for assistance if pain starts .Monitor/document/report to MD PRN any s/sx of CAD: chest pain or pressure especially with activity, etc Further review of Resident #1's Care Plan indicated a focus on area of Hypertension (when the pressure in your blood vessels is too high), and an intervention included Administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate. A record review of Resident #1's Progress Notes, dated 02/04/24 at 2:27 PM, by LVN C, reflected Data: Resident complained of chest pain. Resident was observed sitting in his wheelchair, appeared not to be in any distress. Vital signs were taken and this nurse looked at resident's chart to see if anything was available to be given. Resident did not have an order for nitroglycerin. [Telehealth] was called. Action: Before Resident left he stated he was not having chest pain and that I'm alive. Response: Vitals signs taken BP 118/70 P (pulse) 78 O2 (oxygen) 97% Room Air. [Telehealth] gave an order to give Nitroglycerin 0.4mg 1 tablet sublingual (situated or applied under the tongue) every 5 minutes times 3 doses. If no relief to call 911. Medication retrieved from Nexsys (secure technology to manage controlled medications, STAT/first doses and electronic E-Kits). This nurse gave the entire bottle misinterpreting the order and thought that the whole bottle was 0.4mg. Then realizing the error, Assessed resident, vitals taken again BP 159/108 P 102, No SOB noted, No respiratory distress. Resident was alert and oriented at this time. This nurse then called 911 and then reported it to the DON and called [telehealth]. EMT's arrived, while being taken out on the stretcher, Resident was alert, stable and talking to the nurse and stated he was not having chest pain and that I'm alive. [telehealth MD] asked if Resident was alert and stable and if he was having any adverse reactions. Resident was stable and did not appear to have any adverse reactions. [telehealth MD] stated ok, it's good he went to the hospital and is not having any reactions. [FM] notified at [phone number]. Stated to let her know when we hear back from the hospital. A record review of Resident #1's hospital records, dated 02/04/24, reflected Resident #1 entered the ER on [DATE] at 3:20 PM. The ER records reflected Chief Complaint Patient presents with Drug Overdose per EMS Accidental overdose of nitroglycerine, give 25 -0.4 mg nitro tablets by nursing home staff over a period of 20 minutes . Initial pressure 86 over 42 presently 115 over 68 after 1 liter of fluid. Sinus bradycardia (a slow heart rate) on the monitor at a rate of 56. Further review of the ER records reflected Resident #1 was given a physical exam and his cardiovascular rate and rhythm was Bradycardia present. The ER records reflected Resident #1's final diagnosis included acute chest pain, bradycardia, hypothyroidism, and overdose of nitroglycerin. Resident #1 was admitted to the hospital on [DATE] at 5:47 PM. In an interview on 02/06/24 at 9:10 AM, the DON stated on Sunday (02/04/24) she was contacted by the WCN and told that LVN C gave Resident #1 an entire bottle of nitroglycerin and was sent out to the hospital. The DON stated she went to the facility and LVN C told her that Resident #1 complained of chest pain, so she contacted the MD and was provided an order for 0.4 mg of nitroglycerin. The DON stated, LVN C told her she got confused and thought the entire bottle was 0.4mg and not each tablet. The DON stated LVN C told her she gave Resident #1 the entire bottle, which was 25 tablets. The DON stated the MD and Resident #1's FM were notified. The DON stated she in-serviced and suspended LVN C. She stated she ensured the other residents who had orders for nitroglycerin were not administered the medication and confirmed when they were administered nitroglycerin it was administered per the orders. The DON stated the ADONs audited the medication carts and found there were no issues. The DON stated following the incident, she immediately in-serviced staff on medication administration, nitroglycerin administration, and abuse & neglect. She stated staff were not able to start their shift until they were in-serviced. The DON stated all in-services were completed by 02/05/24. She stated LVN C would be terminated. The DON stated her expectation was for Med Aides and nurses to administer medications per the physician orders, and if they have questions about the orders or medications, they were supposed to get clarification before administering the medication. In an interview on 02/06/24 at 10:17 AM, LVN C stated on Sunday (02/04/24) about noon, Resident #1 started complaining of chest pain, so she notified the WCN, who was the charge nurse. LVN C stated the WCN told her to take Resident #1's vitals and contact the MD. LVN C stated she contacted the MD and was given an order for 0.4 mg of nitroglycerin and if resident continued to have chest pain, then she needed to send Resident #1 to the ER. LVN C stated the WCN pulled the medicine for the emergency kit. She stated the bottle was small and the pills were tiny, so she misinterpreted the dosage amount. LVN C stated she thought the entire bottle was 0.4 mg, so she gave the entire bottle to the Resident #1, which was 25 tablets. She stated it was her first-time administering nitroglycerin. LVN C stated as she was about to leave Resident #1's room, she realized her mistake, but the pills were in his mouth and dissolved. LVN C stated she notified the WCN of her mistake and was told to call 911. She stated 911 was called and she notified the MD and Resident #1's family of the incident. LVN C stated the EMS arrived about 10 minutes after they were contacted. She stated Resident #1's vitals were normal while he was at the facility. LVN C stated she was in-serviced and suspended. In an interview on 02/06/24 at 10:28 AM, the WCN stated on 02/04/24, Resident #1 was complaining of chest pain. The WCN stated LVN C contacted the MD and received an order for nitroglycerin. She stated she pulled the Nitroglycerin from Nexsys and told LVN C to put Resident #1's name and date on the bottle. The WCN stated she told her to give Resident #1 one tablet and then wait to see if the chest pain stopped. She stated about 30 minutes later, LVN C came to her office crying saying she messed up and gave Resident #1 the entire bottle. The WCN stated LVN C stated she thought the entire bottle was 0.4 mg. The WCN stated she told LVN C to call 911 and to take Resident #1's vitals. In a follow up interview on 02/06/24 at 5:11 PM, the DON stated LVN C was a new nurse and got her license in September 2023. The DON stated a licensed nurse skills competency was completed when LVN C was initially hired in October 2023. The DON stated medication administration is a skill that is observed and completed during the competency check. She stated she did not believe any other evaluations had been completed after her initial skills check in October 2023. A record review of the facility's policy titled Medication- Treatment Administration and Documentation Guidelines, dated 02/02/14, reflected Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Fundamental Information: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Point Click Care (PCC) times codes are assigned to medication in order to administer according to manufacturers' guidelines, physician orders or patient choice . Process: 1. Verify labels accurately reflect the physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the MAR three (3) times . 4. Administer the medication according to the physician orders . A policy regarding nursing competency was requested and the facility provided a policy titled Training Requirements, dated 11/29/22. A record review of the policy reflected Policy: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Policy Explanation and Compliance Guidelines: . 3. Competencies and skill set for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles . An IJ was identified to have existed from 02/04/24 through 02/05/24. On 02/06/24 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: A record review of the facility's document titled Associate Disciplinary Memorandum, dated 02/04/24 and completed by the DON, reflected LVN C was suspended due to medication error. A record review of the facility's document titled Termination Report, dated 02/06/24, reflected LVN C was terminated due to safety violations. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON A, reflected the medication carts for the 100 hall was audited and had no issues. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON B, reflected the medication carts for the 200 hall was audited and had no issues. A record review of the facility's in-services titled Medication Pass Policy and Nitroglycerin uses and directions, dated 02/04/24, reflected all Med Aides and nursing staff, were educated on the facility's policy titled Medication- Treatment Administration Documentation Guidelines, dated 02/02/14 and training document Nitroglycerin Oral: Uses, Side Effects, Interactions, Pictures, Warning & Dosing, undated. A record review of the facility's documents titled Validation Checklist Medication Pass, dated 02/04/24, reflected Purpose: To determine if the nurse is performing a medication pass procedure in accordance with the facility's standard of practice. Enter Nurse/Nurse Aide Initial Record observation below. Review findings with the nurse. Provide correction action as needed. The documents reflected ADON A and ADON B completed observations of medication pass on all Med Aides and nurses, which revealed there were no issues. A record review of the facility's in-services titled Abuse and Neglect, dated 02/04/24, reflected all staff were in-serviced on the facility's policy titled Abuse Policy, dated 02/01/21, and completed a posttest titled Resident Abuse Prevention and Reporting, which reflected no issues. Interviews were conducted from 02/06/24 between 11:40 AM and 2:20 PM to 02/07/24 between 10:10 and 10:30, with 3 Med Aides, 4 RNs, 5 LVNs, and two ADONs, from various shifts. The staff all stated they had been in-serviced on medication administration, nitroglycerin administration, and abuse and neglect. The staff were able to identify and define medication errors, and were knowledgeable on procedures for administering all medications, specifically nitroglycerin. The staff were knowledgeable of abuse & neglect policy and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident # 1) reviewed for significant medication errors. On 02/04/24, LVN C failed to ensure Resident #1 was administered nitroglycerin (medication used to prevent or relieve chest pain caused by coronary artery disease by relaxing blood vessels), as ordered by the physician. LVN C dispensed an entire bottle of nitroglycerin, which consisted of 25 (0.4 mg) tablets to Resident #1, when the physician order was for 1 (0.4 mg) tablet. Resident #1 was transferred to the emergency room, his initial blood pressure at the ER was 86/42. The noncompliance was identified as PNC. The IJ began on 02/04/24 and ended on 02/05/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health, hospitalization, or death. The findings included: A record review of the American Heart Associations' guidance on Understanding Blood Pressure Readings, last reviewed on 05/30/23, reflected a normal blood pressure reading would be 120/80. Accessed on 02/16/24 from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings A record review of Resident #1's electronic Face Sheet dated 02/06/24 reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses that included need for assistance with personal care, muscle weakness, unsteadiness on feet, and atherosclerotic heart disease of native coronary artery (caused by plaque buildup in the wall of the arteries that supply blood to the heart). A record review of Resident #1's Optional State Assessment MDS, dated [DATE] indicated Resident #1 had a BIMS score of 11, which indicated the resident's cognition was moderately impaired. A record review of Resident #1's Physician Orders, dated 02/04/24, reflected Nitroglycerin Sublingual Tablet 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for chest pain x 3 does, if no relief call MD, send to ER for further Evaluation. A record review of Resident #1's Care Plan, dated 09/08/22, indicated a focus area of has altered cardiovascular (relating to the heart and blood vessels) status r/t ASHD/CAD and the interventions included . Monitor for complaint of chest pain. Enforce the need to call for assistance if pain starts . Monitor/document/report to MD PRN any s/sx of CAD: chest pain or pressure especially with activity, etc. Further review of Resident #1's Care Plan indicated a focus on area of Hypertension (when the pressure in your blood vessels is too high), and an intervention included Administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate. A record review of Resident #1's Progress Notes, dated 02/04/24 at 2:27 PM, by LVN C, reflected Data: Resident complained of chest pain. Resident was observed sitting in his wheelchair, appeared not to be in any distress. Vital signs were taken and this nurse looked at resident's chart to see if anything was available to be given. Resident did not have an order for nitroglycerin. [Telehealth] was called. Action: Before Resident left he stated he was not having chest pain and that I'm alive. Response: Vitals signs taken BP 118/70 P (pulse) 78 O2 (oxygen) 97% Room Air. [Telehealth] gave an order to give Nitroglycerin 0.4mg 1 tablet sublingual (situated or applied under the tongue) every 5 minutes times 3 doses. If no relief to call 911. Medication retrieved from Nexsys (secure technology to manage controlled medications, STAT/first doses and electronic E-Kits). This nurse gave the entire bottle misinterpreting the order and thought that the whole bottle was 0.4mg. Then realizing the error, Assessed resident, vitals taken again BP 159/108 P 102, No SOB noted, No respiratory distress. Resident was alert and oriented at this time. This nurse then called 911 and then reported it to the DON and called [telehealth]. EMT's arrived, while being taken out on the stretcher, Resident was alert, stable and talking to the nurse and stated he was not having chest pain and that I'm alive. [telehealth MD] asked if Resident was alert and stable and if he was having any adverse reactions. Resident was stable and did not appear to have any adverse reactions. [telehealth MD] stated ok, it's good he went to the hospital and is not having any reactions. [FM] notified at [phone number]. Stated to let her know when we hear back from the hospital. A record review of Resident #1's hospital records, dated 02/04/24, reflected Resident #1 entered the ER on [DATE] at 3:20 PM. The ER records reflected Chief Complaint Patient presents with Drug Overdose per EMS Accidental overdose of nitroglycerine, give 25 0.4 mg nitro tablets by nursing home staff over a period of 20 minutes . Initial pressure 86 over 42 presently 115 over 68 after 1 liter of fluid. Sinus bradycardia (a slow heart rate) on the monitor at a rate of 56. Further review of the ER records reflected Resident #1 was given a physical exam and his cardiovascular rate and rhythm was Bradycardia present. The ER records reflected Resident #1's final diagnosis included acute chest pain, bradycardia, hypothyroidism, and overdose of nitroglycerin. Resident #1 was admitted to the hospital on [DATE] at 5:47 PM. In an interview on 02/06/24 at 9:10 AM, the DON stated on Sunday (02/04/24) she was contacted by the WCN and told that LVN C gave Resident #1 an entire bottle of nitroglycerin and was sent out to the hospital. The DON stated she went to the facility and LVN C told her that Resident #1 complained of chest pain, so she contacted the MD and was provided an order for .4 mg of nitroglycerin. The DON stated, LVN C told her she got confused and thought the entire bottle was .4mg and not each tablet. The DON stated LVN C told her she gave Resident #1 the entire bottle, which was 25 tablets. The DON stated the MD and Resident #1's FM were notified. The DON stated she in-serviced and suspended LVN C. She stated she ensured the other residents who had orders for nitroglycerin were not administered the medication and confirmed when they were administered nitroglycerin it was administered per the orders. The DON stated the ADONs audited the medication carts and found there were no issues. The DON stated following the incident, she immediately in-serviced staff on medication administration, nitroglycerin administration, and abuse & neglect. She stated staff were not able to start their shift until they were in-serviced. The DON stated all in-services were completed by 02/05/24. She stated LVN C would be terminated. The DON stated her expectation was for Med Aides and nurses to administer medications per the physician orders, and if they have questions about the orders or medications, they were supposed to get clarification before administering the medication. In an interview on 02/06/24 at 10:17 AM, LVN C stated on Sunday (02/04/24) about noon, Resident #1 started complaining of chest pain, so she notified the WCN, who was the charge nurse. LVN C stated the WCN told her to take Resident #1's vitals and contact the MD. LVN C stated she contacted the MD and was given an order for .4 mg of nitroglycerin and if resident continued to have chest pain, then she needed to send Resident #1 to the ER. LVN C stated the WCN pulled the medicine for the emergency kit. She stated the bottle was small and the pills were tiny, so she misinterpreted the dosage amount. LVN C stated she thought the entire bottle was .4 mg, so she gave the entire bottle to the Resident #1, which was 25 tablets. She stated it was her first-time administering nitroglycerin. LVN C stated as she was about to leave Resident #1's room, she realized her mistake, but the pills were in his mouth and dissolved. LVN C stated she notified the WCN of her mistake and was told to call 911. She stated 911 was called and she notified the MD and Resident #1's family of the incident. LVN C stated the EMS arrived about 10 minutes after they were contacted. She stated Resident #1's vitals were normal while he was at the facility. LVN C stated she was in-serviced and suspended. In an interview on 02/06/24 at 10:28 AM, the WCN stated on 02/04/24, Resident #1 was complaining of chest pain. The WCN stated LVN C contacted the MD and received an order for nitroglycerin. She stated she pulled the Nitroglycerin from Nexsys and told LVN C to put Resident #1's name and date on the bottle. The WCN stated she told her to give Resident #1 one tablet and then wait to see if the chest pain stopped. She stated about 30 minutes later, LVN C came to her office crying saying she messed up and gave Resident #1 the entire bottle. The WCN stated LVN C stated she thought the entire bottle was .4 mg. The WCN stated she told LVN C to call 911 and to take Resident #1's vitals. A record review of the facility's policy titled Medication- Treatment Administration and Documentation Guidelines, dated 02/02/14, reflected Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments. Fundamental Information: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Point Click Care (PCC) times codes are assigned to medication in order to administer according to manufacturers' guidelines, physician orders or patient choice . Process: 1. Verify labels accurately reflect the physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the MAR three (3) times . 4. Administer the medication according to the physician orders . An IJ was identified to have existed from 02/04/24 through 02/05/24. On 02/06/24 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: A record review of the facility's document titled Associate Disciplinary Memorandum, dated 02/04/24 and completed by the DON, reflected LVN C was suspended due to medication error. A record review of the facility's document titled Termination Report, dated 02/06/24, reflected LVN C was terminated due to safety violations . A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON A, reflected the medication carts for the 100 hall was audited and had no issues. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON B, reflected the medication carts for the 200 hall was audited and had no issues. A record review of the facility's in-services titled Medication Pass Policy and Nitroglycerin uses and directions, dated 02/04/24, reflected all Med Aides and nursing staff, were educated on the facility's policy titled Medication- Treatment Administration Documentation Guidelines, dated 02/02/14 and training document Nitroglycerin Oral: Uses, Side Effects, Interactions, Pictures, Warning & Dosing, undated. A record review of the facility's documents titled Validation Checklist Medication Pass, dated 02/04/24, reflected Purpose: To determine if the nurse is performing a medication pass procedure in accordance with the facility's standard of practice. Enter Nurse/Nurse Aide Initial Record observation below. Review findings with the nurse. Provide correction action as needed. The documents reflected ADON A and ADON B completed observations of medication pass on all Med Aides and nurses, which revealed there were no issues. A record review of the facility's in-services titled Abuse and Neglect, dated 02/04/24, reflected all staff were in-serviced on the facility's policy titled Abuse Policy, dated 02/01/21, and completed a posttest titled Resident Abuse Prevention and Reporting, which reflected no issues. Interviews were conducted from 02/06/24 between 11:40 AM and 2:20 PM to 02/07/24 between 10:10 AM and 10:30 AM, with 3 Med Aides, 4 RNs, 5 LVNs, and two ADONs, from various shifts. The staff all stated they had been in-serviced on medication administration, nitroglycerin administration, and abuse and neglect. The staff were able to identify and define medication errors, and were knowledgeable on procedures for administering all medications, specifically nitroglycerin. The staff were knowledgeable of abuse and neglect policy and procedures.