**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to immediately consult with the resident physician when there was significant change in the resident physical condition for 1 of 4 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced 35 elevated blood pressure readings in the month of [DATE] . The facility failed to notify the physician when Resident #1 had an unwitnessed fall on [DATE] at approximately 080:00, her BP reading was 177/126. Resident #1 had a change in condition and was sent out to the hospital at approximately 10:45 a.m., her BP reading at that time was 197/102, she died at the hospital the following day. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE] at 4:15 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not having their physician consulted on changes in condition requiring medical intervention, caused harm, and could result in the death. of another resident. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnoses of high blood pressure, liver disease, and Lupus (a chronic disease, an autoimmune disease with systemic manifestations including skin rash, erosion of joints or even kidney disease. Record review of a Quarterly MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1's BIMS score was 12 indicating moderate cognitive impairment. The MDS indicated in Section Rejection of Care Resident #1 had not demonstrated any behaviors. The MDS indicated Resident #1 required supervision of one staff with transfers, and dressing, she required limited assistance of one staff with locomotion. Resident #1 required extensive assistance of one staff with personal hygiene. In Section I Active Diagnosis hypertension was marked (high blood pressure). Record review of Resident #1's comprehensive care plan dated [DATE] indicated Resident #1 did not have a care plan for high blood pressure (hypertension). Record review of the consolidated physician orders dated [DATE], indicated Resident #1 was ordered amlodipine 10 milligrams one tablet by mouth two times daily for high blood pressure with the parameters to hold if the systolic blood pressure was less than 100 or the diastolic blood pressure was less than 60 on [DATE]. Resident #1 had a physician order dated [DATE] for Clonidine 0.1 milligram one tablet by mouth every 24 hours as needed for elevated blood pressure with a parameter of administer for a systolic blood pressure greater than 160 or a diastolic blood pressure greater than 90. Record review of the MAR dated [DATE] revealed Resident #1's blood pressures were for the administration of the amlodipine: [DATE] and [DATE] Resident #1 out of the facility *[DATE] AM 165/98 and PM 159/95 *[DATE] AM 147/92 and PM 155/98 *[DATE] PM 154/107 *[DATE] AM 148/103 and PM 138/90 *[DATE] PM 143/90 *[DATE] PM 142/93 *[DATE] AM 160/94 *[DATE] AM 151/101 and PM 139/91 *[DATE] AM 157/108 and PM 160/118 *[DATE] PM 159/96 *[DATE] AM 154/96 [DATE] - [DATE] Resident #1 out of the facility *[DATE] AM 167/102 and PM 146/92 *[DATE] AM 147/96 and 152/95 *[DATE] AM 151/102 and 148/98 *[DATE] AM 144/92 and PM 144/97 *[DATE] PM 149/92 *[DATE] AM 168/99 and PM 153/94 *[DATE] AM 147/96 and PM 139/92 *[DATE] AM 145/101 and PM 159/110 *[DATE] - [DATE] Resident #1 out of facility *[DATE] AM 147/95 *[DATE] AM 172/115 *[DATE] AM 155/98 and PM 148/97 *[DATE] AM 147/93 Record review of the MAR for Clonidine 0.1 milligram indicated Resident #1 had no administrations for the entire month of [DATE]. Record review of an Event Nurses Note dated [DATE] at 8:00 a.m., indicated CNA B notified the nurse that Resident #1 was in the floor. RN A documented when she arrived at the room, Resident #1 was in the floor at the foot of her bed in a large puddle of urine. RN A documented Resident #1 was assisted up to the bathroom. RN A documented Resident #1 was alert and oriented with no neurological deficits. The Event Note indicated Resident #1 fell in her room, the fall was unwitnessed, and there were no injuries, and no pain. The section for orthostatic blood pressures was left blank. The most recent blood pressure was documented sitting to her left arm with the results of 177/126 and the heart rate was 92 and her respirations were 26. The event note indicated the initial treatment was monitoring only, and the area for any new physician's orders was left blank. In the area of Notification of the physician this area was blank on the name of the physician, the time, the responsible party notification and time of notification was all left blank. The intervention prior to the fall was documented by RN A as a low bed, with additional interventions documented with a scheduled toileting program. The Event nurses note indicated there were no physical factors. The Event nurses note indicated in the other information section the responsible party was called several times and the phone number was disconnected. The note indicated RN A called the hospice provider of the fall. Record review of a Fall report dated [DATE] 10:04 a.m., RN A documented Resident #1 attempted to get to the bathroom without assistance and urinated on the floor then slipped in the urine and landed on her buttocks. Resident #1 reported she was trying to go to the bathroom and slipped and fell onto her buttocks. Resident #1 reported no injuries and no pain at this time. Resident #1 reported she did not hit her head. The report indicated Resident #1 was at her baseline status. The report indicated the immediate action taken was Resident #1 was assisted off the floor, taken to the bathroom, incontinent care provided, vital signs obtained and assisted back to her bed. The report indicated Resident #1's skin was assessed for injury and was found to have none. The report indicated Resident #1 ambulated back to bed freely. The report indicated Resident #1 was oriented to time, place, situation and person. The report indicated she was alert. The report indicated there were no environmental factors, and her gait imbalance was the predisposing physiological factor. The report indicated her blood pressure was assessed at 8:45 a.m. and was 152/22 with a heart rate of 88. The report indicated the predisposing factors was Resident #1 ambulated without assistance and urine on the floor may have caused her to slip. The report indicated there were no witnesses to this fall. The fall report indicated the hospice provider was notified at 10:30 a.m. and the family member was notified at [DATE] at 10:19 a.m. The report failed to indicate the resident's primary physician, designee, or the medical director was notified. Record review of the Neurological assessment dated [DATE] indicated the neurological assessment was initiated by RN A at 8:00 a.m. with the blood pressure being 177/126 with the heart rate of 92. The Neurological Assessment failed to provide any vital signs for the 8:15 a.m., and the 8:30 a.m. time frames. The next set of vital signs appearing on the Neurological Assessment was at 8:45 a.m., the blood pressure was 152/55 and the heart rate was 90. The next set of vital signs appearing on the Neurological Assessment was blocked off during the time of 9:45 a.m. - 11:45 a.m. indicating there was one set of vital signs of 197/102 and a heart rate of 90. The assessment indicated Resident #1 eyes opened spontaneously until 10:45 a.m., her verbal response was oriented until 10:45 a.m., her motor responses were obeyed commands, and her pupils were reactive to light until 10:45 a.m. and the hand grips were equal until 10:45 a.m. Record review of a SBAR (a verbal or written communication tool used to help provide essential, concise information, usually during crucial situations) note dated [DATE] at 10:35 a.m., RN A documented Resident #1 had a change of mental status, change of function status, and change of behavior status. The documented blood pressure was 197/102 and the heart rate was 92, respirations were 26, the temperature and oxygen saturation were not obtained on this day. RN A documented Resident #1's blood glucose level was 108. The mental status change was documented as decreased level of consciousness by RN A. The Functional change was documented as falls, swallowing difficulty, and weakness. RN A documented she notified 911 and Resident #1 was sent to the hospital. The SBAR note indicated in the section of physician or designee notification, date and time was all left blank. Record review of an eTransfer dated [DATE] indicated Resident #1 was transferred to the local hospital. The transfer note indicated the reason for the transfer was Resident #1 was found to be unable to speak, change of level of consciousness, and excessive saliva at her mouth. The transfer note indicated Resident #1 was transferred on [DATE] at 10:25 a.m. as an emergency transfer. The transfer note indicated Resident #1's blood pressure was 197/102 with her heart rate of 92 and respirations of 26 per minute. The transfer note indicated Resident #1 was lethargic, not oriented, unclear or no speech, urine incontinence, swallowing problems, unable to bear weight, and her current status was not her baseline. The transfer note indicated in the area of primary physician notification the hospice provider was listed not a physician. Record review of the progress notes dated [DATE] at 10:15 a.m., RN A documented Resident #1 was found lying sideways on her bed, with excessive saliva at her lips. The progress notes further indicated Resident #1 was unable to verbally respond, but does open her eyes, vital signs were obtained, and the crash cart was taken to Resident #1's room. RN A said she was unable to obtain an oxygen saturation due to the equipment not reading on her fingertip. RN A documented Resident #1's blood pressure was 197/102, heart rate 92, and blood glucose was 108. RN A documented EMS was notified and on the way. RN A documented oxygen was applied at 2 liters per nasal cannula. Record review of a hospital record of a CT (imaging test that helps detect diseases and injuries)/Brain scan without contrast medium dated [DATE] at 11:25 a.m., revealed Resident #1 had a massive acute central deep brain hemorrhage with marked intraventricular extensions as above extending into the midbrain. Resident #1 also had a moderate sized acute left external capsule hemorrhage. The results note indicated Resident #1's hemorrhages were both likely hypertensive in etiology. The findings indicated Resident #1 had a massive deep right cerebral hemorrhage present measuring roughly 4.8 x 4.6 x 4.7 centimeters. The included the right basal ganglia, thalamus, surrounding white matter and the midbrain. Extensive intraventricular extension was present, with blood throughout the lateral, third, and fourth ventricles, and fourth ventricular outlet foramina. A second smaller acute parenchymal hemorrhage was present along the left external capsule measuring approximately 3.0 x 2.5 x 1.2 centimeters. During an interview on [DATE] at 1:45 p.m., the Corporate Compliance Nurse said Resident #1's life support was removed, and she expired today. During an interview on [DATE] at 1:58 p.m., the DON said on [DATE] around 8:00 a.m. - 8:15 a.m. the staff heard something and walked into Resident #1's room. The DON said Resident #1 was found to have fallen. The DON said Resident #1 indicated she had not hurt herself. The DON said within a couple of hours Resident #1 was having seizure like activity and was sent to the local emergency room. The DON indicated after reviewing Resident #1's reports of her brain scans Resident #1 had two brain hemorrhages attributed to high blood pressure. During an interview on [DATE] at 2:07 p.m., RN B said CNA C alerted her Resident #1 fell. RN B said she went to get RN A. RN B said RN A was the charge nurse assigned to Resident #1. RN B said the fall occurred around 8:00 a.m. on [DATE]. RN B said Resident #1 was at the end of her bed and was on the floor in urine. RN B said RN A asked Resident #1 if she hit her head and Resident #1 indicated she had not. RN B said she assisted RN A to ambulate Resident #1 to the bathroom. RN B said she informed RN A to be sure and start her neurological assessments. During an interview on [DATE] at 2:13 p.m., CNA C said she was passing ice on [DATE] and had just provided ice to Resident #1 and greeted her good morning. CNA C said she exited the room and was directly across the hall when she heard a loud noise and saw Resident #1 at the foot of her bed going down. CNA C said the room was dark, but she ran over and advised Resident #1 to stay seated she would get the nurse. CNA C said she ran and alerted RN B. During an interview on [DATE] at 3:42 p.m., RN B said neurological checks should be completed when a resident falls. RN B said neurological checks included a full set of vital signs. RN B said the facility does have medication aides who pass medications to 2 of the halls and the nurses give medications on one hall each. During an interview on [DATE] at 3:45 p.m., MA D said she had passed medications to Resident #1. MA D said she had alerted the nurse of past abnormal blood pressures but was never instructed to administer the ordered clonidine. MA D said she was unsure of which nurse she had notified in the past. During an interview on [DATE] at 3:54 p.m., LVN E said today was the first day she had worked in several months. LVN E said she would expect the medication aides to alert her of an abnormal blood pressure. LVN E said she would notify the physician and obtain orders after she rechecked the blood pressure with a manual blood pressure device. LVN E said she would also review the medication record to see what medications were available to lower blood pressures and administer as ordered. LVN E said if she was unable to reach the physician, she would send the resident to the hospital for evaluation. LVN E said when obtaining neurological assessment, a full set of vital signs were required. During an interview on [DATE] at 3:59 p.m., the ADON said she expected the medication aides to alert the nursing staff when they obtain abnormal vital signs. The ADON said then she expected the nurse to review the orders to administer an as needed medication if applicable. The ADON said she expected the nurses to notify the MD with abnormal vital signs. The ADON said chronic high blood pressure could damage the kidneys, cause strokes, and heart attacks. The ADON said neurological assessments populate when you complete the risk management form. The ADON said when the nurse marks a resident had not hit their head then the neurological assessments do not populate. The ADON said this was the reason for neurological assessments on paper as a backup tool. The ADON said she had instructed RN A to notify the physician, the family, and the hospice provider. During an interview on [DATE] at 4:17 p.m., RN A said she was down another hall when RN B came to alert her of Resident #1's fall. RN A said when she entered the room Resident #1 was sitting on the floor at the end of her bed in urine. RN A said she completed an assessment and assisted Resident #1 up and Resident #1 ambulated to the restroom. RN A said Resident #1 indicated she had not hit her head. RN A said she assisted Resident #1 with incontinent care and assisted her back to bed. RN A said she obtained Resident #1's blood pressure and the reading was elevated but she said she contributed the elevated blood pressure to the fall. RN A said she rechecked Resident #1's blood pressure approximately 45 minutes later. RN A said she checked Resident #1 every 15 minutes for her neurological checks but was not monitoring her vital signs every 15 minutes. RN A said around 9:45 a.m. to 10:45 a.m., the Social Worker alerted her to Resident #1 was not responding correctly. RN A said when she entered the room Resident #1 appeared to have a seizure like activity, frothy salvia from the mouth, and not responding although her eyes were open. RN A said EMS was alerted. RN A said she was never taught by the facility to complete any of the forms for the fall nor the neurological assessments. RN A said her work history included emergency room nursing where the patients were monitored by equipment and in the facility, there was not any of this equipment. RN A said she notified the hospice provider of the fall and spoke to Resident #1's routine nurse. RN A said she thought notification to the hospice provider was sufficient. RN A said no one advised her to notify Resident #1's provider or the medical director of the facility. During an interview on [DATE] at 4:37 p.m., the DON said normally the neurological assessments included a full set of vital signs. The DON reviewed the form RN A completed for neurological assessments and indicated she was unsure why this form was used. The DON said the form RN A documented neurological assessments on did not include an area to enter a set of vital signs. The DON said RN A had not completed the SBAR when she had not notified Resident #1's physician or the medical director. The DON reviewed the blood pressures with the surveyor and agreed the blood pressures for [DATE] were elevated and the physician should have been consulted. The DON said high blood pressures over time could lead to strokes. The DON said the computerized medical record system also had alerts set up to notify the nurses when the residents have abnormal findings. The DON said she had in-serviced the medication aides on when to notify the nurses regarding blood pressures and was in the process of in-servicing the nurses on the use of the alerts in the computer system as well as communicating with the medication aides. During an interview on [DATE] at 4:10 p.m., the medical director indicated he had been notified of the immediate jeopardy by the Administrator and this was discussed in a meeting with the team. The medical director said he was not Resident #1's primary physician. The medical director said he expected the hospice physician to have oversight of Resident #1's care. During a return call on [DATE] at 11:45 a.m., Resident #1's identified physician on her face sheet indicated he was not the primary physician for Resident #1 he was the hospice physician only. The physician said he expected the medical director of the facility to have oversight of Resident #1's care. The physician indicated he was the physician who would address any palliative needs. The physician said although he believed he was not Resident #1's primary physician he said he as a physician he would expect Resident #1 to have received any as needed medications to lower her blood pressure. The physician indicated the blood pressure readings were abnormal and he believed over time these abnormal findings could lead to complications related to neurologic incidents (stroke) or cardiovascular incidents (heart attack). Record review of a Notifying the Physician of Change in Status policy dated 2003 indicated the nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the interact tool, Change in Condition-When to Notify the physician, nurse practitioner, or physician's assistant to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. The Administrator was notified on [DATE] at 6:00 p.m. that an immediate jeopardy situation was identified due to the above failures. The Administrator was provided the template on [DATE] at 6:03 p.m. The POR was submitted by Administrator and accepted on [DATE] at 12:01 and indicated the following: Alleged Issues: The facility failed to: 1.36 opportunities to administer a Clonidine for systolic blood pressure of >160 or a diastolic blood pressure of > than 90 in the month of October. 2.Hypertensive post fall on [DATE] blood pressure 177/123. Plan of Removal: Actions: 1.As of [DATE] resident was transferred to the hospital for evaluation. 2.All residents who had an unwitnessed fall in the last 30 days were assessed for any neurological deficits by Compliance Nurse, DON, and ADON on [DATE] to include vital signs. No additional findings were discovered. 3.The Regional Compliance Nurse and Director of Nursing reviewed blood pressures with pulses for all residents over the last 30 days on [DATE] and the physician was notified for all elevated blood pressures and pulses. No additional blood pressures or pulses were identified that were outside of ordered parameters for physician notification. 4.The Regional Compliance Nurse and Director of Nursing completed an audit for all anti-hypertensive medications on [DATE] to ensure parameters were in place. In-services: 1.All charge nurses were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A) Abuse and Neglect to include Failure to recognize and treat an elevated blood pressure and notify the physician of a change in condition. B) Fall prevention policy to include assessing for change in condition that could contribute to a fall. C) Completing entries into Risk Management of PCC for Falls and completing Fall Event Note and Fall Risk assessment. D) Neurological checks including vital signs will be performed by the charge nurse on all residents who have an unwitnessed fall or hit their head during the fall. E) Promptly and correctly assessing a resident when a change of condition has been identified and Notification of change of condition to the DON, Physician, RP immediately including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits after a fall, increased or decreased BP/Pulse, etc. F) Checking clinical alerts and addressing them timely. G) Following parameters when administering medications to identify when a PRN medication needs to be administered. Additional instructions will be included for the CMA on the EMAR to notify the charge nurse when parameters are met for PRN medication administration. 2.All Certified Medication Aides were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all CMAs including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A.Abuse and Neglect to include Failure to recognize and an elevated blood pressure and notify the charge nurse of a change in condition. B.Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C.Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D.Notification of the charge nurse when holding medications due to vital signs being outside of parameters. Also, notification of the charge nurses when parameters are met for a PRN medication to be administered. 3) All other clinical staff were in-serviced on [DATE] by the Administrator, DON, ADON regarding the following and all clinical staff including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. A.Abuse and Neglect to include notifying the charge nurse of a change in condition. B.Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C.Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D.The Medical Director was notified by the Administrator on [DATE] of the facility failures. E.The Regional Compliance Nurse visited the facility [DATE] to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, and notifying the physician on change in status. F.An AD HOC QAPI meeting will be held on [DATE] by the Interdisciplinary Team to discuss the facility failures and plan of correction. G.The Administrator and DON will implement this written Plan of Removal and will continue to monitor for completion and compliance. Plan of removal date: [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1.During an interview on [DATE] at 4:10 p.m., the Medical Director confirmed he was notified of the IJ situation and an interim QAPI meeting was completed. 2.Record review of an Off Cycle QA Meeting Document dated [DATE] indicated the committee reviewed the company nursing practices relate to notification of the physician, neurological checks, monitoring medications, incident and accident policy and procedure and noted a need for immediate change process. The QA meeting documented the facility had a system failure related to a resident fall incident that resulted in the hospitalization and subsequent death of the resident that resulted in an immediate need of review of this system. Areas of concern that were identified were listed for review: facility failed to check vital signs with neurological checks for a resident after a fall, facility failed to assess, identify, and document changes in the resident's neurological condition, facility failed to notify the physician of a change in the resident's condition related to elevated blood pressure and pulse and the facility failed to adequately control a resident's blood pressure and pulse by not administering an as needed medication as indicated by parameters ordered by the physician. The committee put in place the DON and Administrator would monitor the systems weekly to ensure continuous compliance was met. Committee members were reviewed as attending were the Medical Director, Administrator, the DON, ADON, Regional Compliance Nurse, Area Director of Operations, Clinical Services Directors, and the [NAME] President. 3.Record review of an undated Adverse Drug Reaction Monitoring policy indicated the policy of this facility to strive to avoid the occurrences of adverse drug reactions through the combined efforts of the physician pharmacist, and nursing staff. Any history of adverse drug reactions specific to individual resident are flagged in the medication administration record and clinical record. Medication reference materials are readily available to nursing staff. The Quality Assurance Committee evaluates all adverse drug reaction incidents. 4.Record review of an undated Event Reporting policy and procedure indicated the facility will complete an event report on variance that occur with the facility. Variances included falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement or behavior that affects other All events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident any physician's orders should be followed. 5.Record review of a Neurologic Checks policy and procedure dated 2003 indicated neurologic checks are a combination of objective observations and measurements done to monitor neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration 4. Assess vital signs- pulse, respirations, and blood pressure. 5. Assess eye response 6. Assess best verbal response .7. Assess best motor response .8. Use a penlight to check response of the pupils. 9. Check grip of hand and ability to squeeze hand. 10. All deteriorations in neurological status will be immediately report to the physician. The nurse will document assessment and the time of physician notification in the clinical record. 6.Record review of a Fall/Ambulation Difficulty policy dated 2003 indicated More than half of falls are related to medically diagnosed conditions. Many residents will have more than one diagnosed condition Assess risk factors .risk factors identified for all residents .Reducing environmental hazards .assessment of gait/balance .evaluate footwear .Review medications .review daily routines .prevention of unsafe transfers/ambulation address social and psychological needs . 7.Record review of a Preventive Strategies to Reduce Fall Risk dated 2003 and revised on [DATE]. The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors whole maintaining or improving the resident's mobility. 8.Record review of a Notifying the Physician of Change in Status policy dated 2003 indicated the nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the interact tool, Change in Condition-When to Notify the physician, nurse practitioner, or physician's assistant to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 9.Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. 10. Record review of the undated Abuse Neglect Policy indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart 7. Neglect: is the failure of the facility, its employees or s[TRUNCATED]

**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 any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1's physician ordered Clonidine for high blood pressure 35 times during the month of [DATE] that resulted in the death of Resident #1. An Immediate Jeopardu (IJ) situation was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE] at 4:15 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This failure could place residents not receiving blood pressure medications as prescribed at risk for strokes, heart attacks, kidney damage, and even death. Findings included: Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female who admitted on [DATE] with the diagnoseis of high blood pressure, liver disease, and Lupus (a chronic disease, an autoimmune disease with systemic manifestations including skin rash, erosion of joints or even kidney disease). Record review of a Quarterly MDS dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1's BIMS score was 12 indicating moderate cognitive impairment. The MDS indicated in Section Rejection of Care Resident #1 had not demonstrated any behaviors. The MDS indicated Resident #1 required supervision of one staff with transfers, and dressing, she required limited assistance of one staff with locomotion. Resident #1 required extensive assistance of one staff with personal hygiene. In Section I Active Diagnosis hypertension was marked (high blood pressure). Record review of Resident #1's comprehensive care plan dated [DATE] indicated Resident #1 did not have a care plan for high blood pressure (hypertension). Record review of the consolidated physician orders dated [DATE], indicated Resident #1 was ordered amlodipine 10 milligrams one tablet by mouth two times daily for high blood pressure with the parameters to hold if the systolic blood pressure was less than 100 or the diastolic blood pressure was less than 60 on [DATE]. Resident #1 had a physician order dated [DATE] for Clonidine 0.1 milligram one tablet by mouth every 24 hours as needed for elevated blood pressure with a parameter of administer for a systolic blood pressure greater than 160 or a diastolic blood pressure greater than 90. Record review of the MAR dated [DATE] revealed Resident #1's blood pressures were for the administration of the amlodipine: [DATE] and [DATE] Resident #1 out of the facility *[DATE] AM 165/98 and PM 159/95 *[DATE] AM 147/92 and PM 155/98 *[DATE] PM 154/107 *[DATE] AM 148/103 and PM 138/90 *[DATE] PM 143/90 *[DATE] PM 142/93 *[DATE] AM 160/94 *[DATE] AM 151/101 and PM 139/91 *[DATE] AM 157/108 and PM 160/118 *[DATE] PM 159/96 *[DATE] AM 154/96 [DATE] - [DATE] Resident #1 out of the facility *[DATE] AM 167/102 and PM 146/92 *[DATE] AM 147/96 and 152/95 *[DATE] AM 151/102 and 148/98 *[DATE] AM 144/92 and PM 144/97 *[DATE] PM 149/92 *[DATE] AM 168/99 and PM 153/94 *[DATE] AM 147/96 and PM 139/92 *[DATE] AM 145/101 and PM 159/110 *[DATE] - [DATE] Resident #1 out of facility *[DATE] AM 147/95 *[DATE] AM 172/115 *[DATE] AM 155/98 and PM 148/97 *[DATE] AM 147/93 Record review of the MAR for Clonidine 0.1 milligram indicated Resident #1 had no administrations for the entire month of [DATE]. Record review of a hospital record of a CT (imaging test that helps detect diseases and injuries)/Brain scan without contrast medium dated [DATE] at 11:25 a.m. revealed Resident #1 had a massive acute central deep brain hemorrhage with marked intraventricular extensions as above extending into the midbrain. Resident #1 also had a moderate sized acute left external capsule hemorrhage. The results note indicated Resident #1's hemorrhages were both likely hypertensive in etiology. The findings indicated Resident #1 had a massive deep right cerebral hemorrhage present measuring roughly 4.8 x 4.6 x 4.7 centimeters. The included the right basal ganglia, thalamus, surrounding white matter and the midbrain. Extensive intraventricular extension was present, with blood throughout the lateral, third, and fourth ventricles, and fourth ventricular outlet foramina. A second smaller acute parenchymal hemorrhage was present along the left external capsule measuring approximately 3.0 x 2.5 x 1.2 centimeters. During an interview on [DATE] at 1:45 p.m., the Corporate Compliance Nurse said Resident #1's life support was removed, and she expired today. During an interview on [DATE] at 1:58 p.m., the DON said on [DATE] around 8:00 a.m. - 8:15 a.m. the staff heard something and walked into Resident #1's room. The DON said Resident #1 was found to have fallen. The DON said Resident #1 indicated she had not hurt herself. The DON said within a couple of hours Resident #1 was having seizure like activity and was sent to the local emergency room. The DON indicated after reviewing Resident #1's reports of her brain scans Resident #1 had two brain hemorrhages attributed to high blood pressure. During an interview on [DATE] at 3:45 p.m., MA D said she had passed medications to Resident #1. MA D said she had alerted the nurse of past abnormal blood pressures but was never instructed to administer the ordered clonidine. MA D said she was unsure of which nurse she had notified in the past. During an interview on [DATE] at 3:54 p.m., LVN E said today was the first day she had worked in several months. LVN E said she would expect the medication aides to alert her of an abnormal blood pressure. LVN E said she would notify the physician and obtain orders after she rechecked the blood pressure with a manual blood pressure device. LVN E said she would also review the medication record to see what medications were available to lower blood pressures and administer as ordered. LVN E said if she was unable to reach the physician, she would send the resident to the hospital for evaluation. LVN E said when obtaining neurological assessment, a full set of vital signs were required. During an interview on [DATE] at 3:59 p.m., the ADON said she expected the medication aides to alert the nursing staff when they obtain abnormal vital signs. The ADON said then she expected the nurse to review the orders to administer an as needed medication if applicable. The ADON said she expected the nurses to notify the MD with abnormal vital signs. The ADON said chronic high blood pressure could damage the kidneys, cause strokes, and heart attacks. The ADON said neurological assessments populate when you complete the risk management form. The ADON said when the nurse marks a resident had not hit their head then the neurological assessments do not populate. The ADON said this was the reason for neurological assessments on paper as a backup tool. The ADON said she had instructed RN A to notify the physician, the family, and the hospice provider. During an interview on [DATE] at 4:37 p.m., the DON said normally the neurological assessments included a full set of vital signs. The DON reviewed the form RN A completed for neurological assessments and indicated she was unsure why this form was used. The DON said the form RN A documented neurological assessments on did not include an area to enter a set of vital signs. The DON said RN A had not completed the SBAR when she had not notified Resident #1's physician or the medical director. The DON reviewed the blood pressures with the surveyor and agreed the blood pressures for [DATE] were elevated and the physician should have been consulted. The DON said high blood pressures over time could lead to strokes. The DON said the computerized medical record system also has alerts set up to notify the nurses when the residents have abnormal findings. The DON said she had in-serviced the medication aides on when to notify the nurses regarding blood pressures and was in the process of in-servicing the nurses on the use of the alerts in the computer system as well as communicating with the medication aides . During an interview on [DATE] at 4:10 p.m., the medical director indicated he had been notified of the immediate jeopardy by the Administrator and this was discussed in a meeting with the team. The medical director said he was not Resident #1's primary physician. The medical director said he expected the hospice physician to have oversight of Resident #1's care. During a return call on [DATE] at 11:45 a.m., Resident #1's identified physician on her face sheet indicated he was not the primary physician for Resident #1 he was the hospice physician only. The physician said he expected the medical director of the facility to have oversight of Resident #1's care. The physician indicated he was the physician who would address any palliative needs. The physician said although he believed he was not Resident #1's primary physician he said he as a physician would expect Resident #1 to have received any as needed medications to lower her blood pressure. The physician indicated the blood pressure readings were abnormal and he believed over time these abnormal findings could lead to complications related to neurologic incidents (stroke) or cardiovascular incidents (heart attack). Record review of the undated Abuse Neglect Policy indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined in this subpart 7. Neglect: is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention: 4. The facility will be responsible to identify, correct and intervene.10. in situations of possible abuse/neglect occurrences, patterns, trends that may constitute abuse. Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. The Administrator was notified on [DATE] at 6:00 p.m. that an immediate jeopardy situation was identified due to the above failures. The Administrator was provided the template on [DATE] at 6:03 p.m. The facility's plan of removal was accepted on [DATE] at 12:21 p.m. and included the following: Alleged Issues: The facility failed to: 1.36 opportunities to administer a Clonidine for systolic blood pressure of >160 or a diastolic blood pressure of > than 90 in the month of October. 2.Hypertensive post fall on [DATE] blood pressure 177/123. Plan of Removal: Actions: 1.As of [DATE] resident was transferred to the hospital for evaluation. 2.All residents who had an unwitnessed fall in the last 30 days were assessed for any neurological deficits by Compliance Nurse, DON, and ADON on [DATE] to include vital signs. No additional findings were discovered. 3.The Regional Compliance Nurse and Director of Nursing reviewed blood pressures with pulses for all residents over the last 30 days on [DATE] and the physician was notified for all elevated blood pressures and pulses. No additional blood pressures or pulses were identified that were outside of ordered parameters for physician notification. 4.The Regional Compliance Nurse and Director of Nursing completed an audit for all anti-hypertensive medications on [DATE] to ensure parameters were in place. In-services: 1.All charge nurses were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all nurses including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A) Abuse and Neglect to include Failure to recognize and treat an elevated blood pressure and notify the physician of a change in condition. B) Fall prevention policy to include assessing for change in condition that could contribute to a fall. C) Completing entries into Risk Management of PCC for Falls and completing Fall Event Note and Fall Risk assessment. D) Neurological checks including vital signs will be performed by the charge nurse on all residents who have an unwitnessed fall or hit their head during the fall. E) Promptly and correctly assessing a resident when a change of condition has been identified and Notification of change of condition to the DON, Physician, RP immediately including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits after a fall, increased or decreased BP/Pulse, etc. F) Checking clinical alerts and addressing them timely. G) Following parameters when administering medications to identify when a PRN medication needs to be administered. Additional instructions will be included for the CMA on the EMAR to notify the charge nurse when parameters are met for PRN medication administration. 2. All Certified Medication Aides were in-serviced on [DATE] by the Administrator, DON, and ADON regarding the following and all CMAs including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. The Admin and DON will be in-serviced by the Regional Compliance Nurse. A. Abuse and Neglect to include Failure to recognize and an elevated blood pressure and notify the charge nurse of a change in condition. B. Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C. Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D. Notification of the charge nurse when holding medications due to vital signs being outside of parameters. Also, notification of the charge nurses when parameters are met for a PRN medication to be administered. 3) All other clinical staff were in-serviced on [DATE] by the Administrator, DON, ADON regarding the following and all clinical staff including agency staff, new hires, and PRN staff not in-serviced on [DATE] will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. A. Abuse and Neglect to include notifying the charge nurse of a change in condition. B. Fall prevention policy to include notifying the charge nurse of change in condition that could contribute to a fall. C. Notification of change of condition to the Charge Nurse including any change in neurological status. Ex: altered level of consciousness, behavior/mood changes, headaches, decrease in decreased mobility, or a change in eating habits. D. The Medical Director was notified by the Administrator on [DATE] of the facility failures. E. The Regional Compliance Nurse visited the facility [DATE] to review all audits and provide additional training as needed regarding Abuse & Neglect, Neuro checks, and notifying the physician on change in status. F. An AD HOC QAPI meeting will be held on [DATE] by the Interdisciplinary Team to discuss the facility failures and plan of correction. G. The Administrator and DON will implement this written Plan of Removal and will continue to monitor for completion and compliance. Plan of removal date: [DATE] On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. During an interview on [DATE] at 4:10 p.m., the Medical Director confirmed he was notified of the IJ situation and an interim QAPI meeting was completed. 2. Record review of an Off Cycle QA Meeting Document dated [DATE] indicated the committee reviewed the company nursing practices relate to notification of the physician, neurological checks, monitoring medications, incident and accident policy and procedure and noted a need for immediate change process. The QA meeting documented the facility had a system failure related to a resident fall incident that resulted in the hospitalization and subsequent death of the resident that resulted in an immediate need of review of this system. Areas of concern that were identified were listed for review: facility failed to check vital signs with neurological checks for a resident after a fall, facility failed to assess, identify, and document changes in the resident's neurological condition, facility failed to notify the physician of a change in the resident's condition related to elevated blood pressure and pulse and the facility failed to adequately control a resident's blood pressure and pulse by not administering an as needed medication as indicated by parameters ordered by the physician. The committee put in place the DON and Administrator would monitor the systems weekly to ensure continuous compliance was met. Committee members were reviewed as attending were the Medical Director, Administrator, the DON, ADON, Regional Compliance Nurse, Area Director of Operations, Clinical Services Directors, and the [NAME] President. 3. Record review of an undated Adverse Drug Reaction Monitoring policy indicated the policy of this facility to strive to avoid the occurrences of adverse drug reactions through the combined efforts of the physician pharmacist, and nursing staff. Any history of adverse drug reactions specific to individual resident are flagged in the medication administration record and clinical record. Medication reference materials are readily available to nursing staff. The Quality Assurance Committee evaluates all adverse drug reaction incidents. 4. Record review of an undated Event Reporting policy and procedure indicated the facility will complete an event report on variance that occur with the facility. Variances included falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement or behavior that affects other All events resulting in a change in status of a resident must be reported immediately to the attending physician and family member/legal representative of the resident any physician's orders should be followed. 5. Record review of a Neurologic Checks policy and procedure dated 2003 indicated neurologic checks are a combination of objective observations and measurements done to monitor neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration 4. Assess vital signs- pulse, respirations, and blood pressure. 5. Assess eye response 6. Assess best verbal response .7. Assess best motor response .8. Use a penlight to check response of the pupils. 9. Check grip of hand and ability to squeeze hand. 10. All deteriorations in neurological status will be immediately report to the physician. The nurse will document assessment and the time of physician notification in the clinical record. 6. Record review of a Fall/Ambulation Difficulty policy dated 2003 indicated More than half of falls are related to medically diagnosed conditions. Many residents will have more than one diagnosed condition Assess risk factors .risk factors identified for all residents .Reducing environmental hazards .assessment of gait/balance .evaluate footwear .Review medications .review daily routines .prevention of unsafe transfers/ambulation address social and psychological needs . 7. Record review of a Preventive Strategies to Reduce Fall Risk dated 2003 and revised on [DATE]. The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors whole maintaining or improving the resident's mobility. 8. Record review of a Notifying the Physician of Change in Status policy dated 2003 indicated the nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medial attention. This facility utilizes the interact tool, Change in Condition-When to Notify the physician, nurse practitioner, or physician's assistant to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 9. Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. 11. Record review of an in-service Abuse and Neglect dated [DATE] indicated: Charge Nurses-Abuse and Neglect including failure to recognize and treat an elevated blood pressure and notify the physician of the change in condition. Medication Aides: Abuse and Neglect including failure to recognize and an elevated blood pressure and notify the charge nurse of a change of condition. All other clinical staff: Abuse and Neglect including notifying the charge nurse in a change of condition. The in-service sign in page indicated 29 staff members were in-serviced. 12. Record review of an in-service Vital Signs and Parameters dated [DATE] indicated: respiratory rate 12-18 breaths per minute; temperature for elderly 97.8 - 99 degrees Fahrenheit; Blood pressure hypertension considered any measurement greater than 140/90 and hypotension was any blood pressure reading below 90/60. Normal blood pressure for the elderly 120/80 and pre-hypertension was 121 - 139. Pulse normal heart rate for elderly 60-100 beats per minute. Medication Aides: notify your charge nurse with vital signs outside of the parameters. Charge nurses: check for any PRN meds. Find out the doctors preferred parameters .Notify the doctors with vital signs outside of these parameters. The in-service sign in page indicated 13 nurses and mediation aides signed the in-service. 13. Record review of an in-service Fall Prevention dated [DATE] indicated 1. Ask the resident immediately after their fall if they were hungry, pain, bored, or needed the bathroom. Look: at the footwear, bed, equipment, call light, belongings, and incontinent. Ask yourself: was there a change, what was the resident doing, was there a recent change in lab work, a recent acute illness, medication factors, new medications, education to staff, and prevention. The in-service indicated 25 staff members signed the in-service. 14. Record review of an in-service dated [DATE] Clinical Alerts-Nurses: in-service on the use of clinical alert notifications on the facility's clinical chart dashboard. The in-service indicated 9 nurses signed the in-service. 15. Record review of an in-service dated [DATE] Incident Reports: in-service provided step by step instructions on completing the incident report. The in-service indicated 11 nurses were in-serviced. 16. Record review of an in-service dated [DATE] Neurological Checks including vital signs indicated neuros must be started immediately with all unwitnessed falls or witnessed falls with head involvement. This included the face, scalp, ear or mouth. Neurological assessments may be completed on paper, but they must be entered into the computer to the end of the shift. Ensure in report the neurological checks were passed to the next nurse. The in-service provided a paper copy of the neurological assessments with a vital sign section at the top. The in-service was signed by 11 nurses. 17. Record review of an in-service Notification dated [DATE] indicated if a resident had a change of condition, whether it is from a fall or having abnormal vital signs, you must contact the doctor first, then their hospice, and family. If you are not able to reach them, then you should keep trying until you do. An instruction list was provided indicating to promptly and correctly assess a resident when a change of condition had been identified/reported This in-service was signed by 11 nurses. Record review of a Medication Administration Policy dated 2003 indicated all medication are administer by licensed medical or nursing personnel. 7. All as needed medication orders must specify the reason and frequency for use. As needed medications are to be charted on the medication administration record. And explanation as to symptoms prior to administration and results are to be documented. During interviews on [DATE] between 2:45 p.m. and 4:10 p.m., LVN E, L, M and Q were able to correctly identify when to notify the physician, correctly identify a change of condition, identifying of abnormal vital signs, monitoring of abnormal findings using the facility's computerized system, steps to complete an incident report, identification of abuse and neglect situations, when to report abuse/neglect, administering as needed medications to alleviate symptoms such as hypertension. CNAs C, G, K, N, O, and P all could correctly identify abuse/neglect, process in identifying a change of condition with a resident, and prevention of falls. MA D could correctly identify parameters of vital signs, when to notify the charge nurses, fall prevention, process when noted changes of condition in a resident, and abuse and neglect. Activity staff H, and dietary staff F could identify abuse and neglect, and the process for alerting the nurse when a resident had a change of condition. The DON and ADON indicated they would be in-serving staff prior to their on coming shifts until all staff were in-serviced. The DON and ADON indicated they would be monitoring the clinical data dashboard to ensure changes of condition were recognized. The DON and Administrator would be monitoring all systems to ensure compliance. On [DATE] at 4:15 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administration of medications for 1 of 1 residents (Resident #1) reviewed for medication omission. 1. the facility failed to follow their protocol by failing to reorder a prescribed medication timely to prevent seizures, and Resident #1 missed two doses of medication, because his medication was not available and he had two back-to-back seizures and was taken to the hospital. (Clobazam (Onfi), used along with other medicines to treat seizures associated with Lennox-Gastaut syndrome, which is a severe condition characterized by repeated seizures (epilepsy) that begin early in life). 2. the facility did not reorder Resident #1's seizure medication until the day he went to the hospital and the facility did not notify his physician that he missed his medication. An IJ was identified on 5/17/23 at 2:30 p.m. The IJ was removed on 5/18/23 at 4:20 p.m. While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to monitor interventions and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of adverse medication effects and/or not receiving the therapeutic benefits of their medications, prescribed by the physician. Findings included: Record review of a face sheet dated 5/16/23 indicated Resident #1 was a [AGE] year-old male admitted to the facility 11/19/22 with diagnoses of epilepsy, unspecified intellectual disabilities, attention-deficit hyperactivity disorder, mild cognitive impairment of uncertain or unknown etiology, and presence of neurostimulator. Record review of an MDS assessment dated [DATE] indicated Resident #1 had moderate impaired cognition. He was independent with personal hygiene, and limited assistance with bathing. Record review of a care plan with a revision date of 03/08/23 indicated Resident #1 had a seizure disorder with an intervention to give seizure medication as ordered by the doctor. Physician orders dated 4/25/23 indicated Resident #1 was to receive Onfi 20mg tablet, 1 tablet at bedtime for prevention of seizure. Record review of Medication Administration Record dated May 2023 indicated Onfi oral tablet 20 mg, give 1 tablet by mouth at bedtime. Last documented dose was given on 5/11/23. Record review of nurses notes dated 5/13/23 indicated CMA C documented medication (Onfi) is not in, and is not in the pyxis (a cart used to store medications). Nurse progress notes dated 5/14/23 at 6:00 a.m. written by LVN B indicated Resident #1 was transferred to the hospital related to having two seizures back-to-back. During an interview on 5/16/23 at 12:07 p.m. Resident #1 was in his room eating lunch. Resident #1 said he was treated well by staff, and all his needs were met. Resident #1 said he received his medications, but sometimes they were late because of the pharmacy, but he always received them. Resident #1 said he had to go to the hospital recently due to having a seizure, but did not remember too much about it, but said he thought he had taken his medications. During an interview on 5/16/23 at 12:15 p.m. the Administrator said on Friday 5/12/23 Resident #1 said he did not get his seizure medication at bedtime. Administrator said LVN A signed it off as being given but signed it off before discovering the medication was not in the facility. The Administrator said Resident #1's medication was not reordered and caused harm to the resident. During an interview on 5/16/23 at 1:32 p.m. the ADON said medications were to be reordered 5-7 days before the last dose of medication . Narcotics needed to be reordered 3-5 days before the last dose of medication. ADON said there had never been a previous problem with meds not being reordered. The ADON said any of the nurses who passed Resident #1's medications could have reordered the medication for it ran out. During an interview on 5/16/23 at 2:28 p.m. CMA C said she had been a med aide for 17-18 years and worked the 2-10 shift. CMA C said on 5/13/23 she documented in Resident #1's progress notes that his Onfi was not in the facility. CMA C said she was told the medication had been reordered but could not remember who told her. CMA C said she told the nurse working (could not remember her name) to check and see if the medicine was in the pyxis). CMA C said she did not think missing 1 dose would cause a seizure and did not check to see if the medication had been reordered. CMA C said she was aware how important this medication was for the resident to receive. During a phone interview on 5/16/23 at 2:46 p.m. LVN A said that on 5/12/23, CMA C asked her to check the pyxis to check to see if the Onfi for Resident #1 was in it. LVN A looked and the medication was not in there. LVN A said she asked LVN H about the medication and was told if it is not in the cart, we don't have it. LVN A said she thought the medication had been reordered but did not check to see if it was. LVN A said on the MAR for Resident #1, on 5/12/23, she signed off that she had given the Onfi prior to discovering she did not have the medication. LVN A stated the Onfi was not given on 5/12/23. LVN A stated the physician and DON were not notified. LVN A said she was not aware of any other resident missing a dose of medicine. During an interview on 5/16/23 at 3:15 p.m. the DON and the Compliance Nurse said LVN A had been suspended pending investigation. DON said any of the staff passing Resident #1's medications could have reordered the medication. Compliance nurse and DON confirmed Resident #1 missed his dose of Onfi on 5/12/23 and 5/13/23. The DON confirmed the dose of Onfi on 5/12/23 was signed off as being given by LVN A but had not been given, as LVN A signed the medication off prior to realizing the medication was not available. DON said someone who had been passing his meds should have checked to see if the medication had been reordered as it was very important for the resident to receive it. During a phone interview on 5/16/23 at 3:45 p.m. LVN B was questioned about documenting a 1 which signified away from facility with meds, on the MAR on 5/14/2023 for Resident #1's dose of Onfi. LVN B said it was incorrect documentation. LVN B said it was Resident #1's roommate who was actually out of the facility. LVN B said she did not know why she clicked on it (the 1). LVN B said the medication was given, and she was aware of how important this medications was. During a phone interview on 5/17/23 at 12:31 p.m. the facility Medical Director said there was a small potential that missing 2 doses of Onfi could have caused Resident #1 to have a seizure but fairly unlikely. During a phone interview on 5/17/23 at 1:47 p.m. the Neurologist assistant stated the physician said, if Resident #1 had missed 2 doses of his Onfi, there was the potential of that causing him to have a seizure, but Resident #1 , had seizures so it was hard to say it was the cause, we will never know. The neurologist assistant said the emergency room physicians did not know Resident #1's history, and that the Neurologist had treated Resident #1 for years, and as long as Resident #1 was on his medication, he was good, and not worried about it. Assistant said labs are not drawn routinely as long as Resident #1 was stable. Record review of hospital records dated 5/16/23 revealed Resident #1 was admitted to the hospital on [DATE] at 6:35 a.m. Hospital physician documentation indicated the following: At this time it is my impression patient had a seizure from the abrupt discontinuation of clobazam (Onfi) which is a known complication. Diagnoses included seizure, volume depletion, electrolyte abnormality and withdrawal from clobazam. Resident #1 was discharged back to the nursing home on 5/14/2023 9:13 a.m. Record review of an Ordering Medications policy dated 2003 indicated the following: .reorder medication three to five days in advance of need to assure and adequate supply is on hand . An Immediate Jeopardy (IJ) was identified on 05/17/2023 at 2:30 p.m., due to the above failures. The Administrator was notified of the IJ, and the IJ template was provided on 5/17/2023 at 3:02 p.m. The Plan of removal was accepted on 5/18/2023 at 3:26 p.m., and included the following: 5/18/20224 Plan of Removal Problem: F755 Pharmacy Services Resident #1 was transferred to the hospital on 5/14/2023. Resident #1 returned to the facility on 5/14/2023. All medications ordered for Resident #1 were audited and verified that adequate supply is present. Audit completed by DON/ADON as of 5/17/2023. Onfi was reordered and administered for resident #1 on 5/14/2023. Administrator/Regional Compliance Nurse/ DON/ADON reviewed Medication Reorder policy and Medication administration policy as of 5/17/2023. DON or designee will review all orders daily to assure policies and procedures are being followed. Interventions: As of 5/17/2023, 100% audit was completed on all resident medications including anticonvulsants to ensure residents are receiving the physician ordered dose. The audit was completed by DON, ADON and Regional Compliance Nurse. No additional omissions were discovered. All resident medications including anticonvulsant medications were verified that they match the ordered dose as of 5/17/2023 by DON, ADON and Regional Compliance Nurse. All resident seizure orders match current physician orders. A Medication error completed as of 5/17/2023 by DON utilizing the medication error form. Pharmacy Consultant was notified of med error as of 5/17/2023 by DON. Ad hoc QAPI meeting was completed with MD and IDT team as of 5/17/2023 to review med error and root cause analysis, and plan of removal. The following in-services were initiated by the DON, ADON and Regional Nurse and completed as of 5/17/23 at 6pm. All Licensed Nurses or Certified Medication Aides not in serviced by 5/17/23 will be in-serviced prior to starting their next shift. In-services will be ongoing for all new hires before they assume their duties. The DON/ADON/Regional Nurse are responsible for conducting these in-services. Licensed Nurses will be in-serviced on: 5 Rights of Medication administration Reporting Medication error that has occurred or found immediately to Physician and DON Re-ordering medications timely to ensure a 5-7-day supply is present. Charge nurses and med aides are both responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply with Medication Aides three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse/Medication Aide will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. Notification of the MD and DON immediately for any resident medications that will not be administered as ordered. Certified Medication Aides will be in-serviced on: 5 Rights of Medication Administration Reporting Medication error that has occurred or found immediately to charge nurse and DON. Re-ordering medications timely to ensure a 5-7 day supply is present. Charge nurses and med aides are both responsible for the re-ordering of medications. Charge nurses will be responsible for auditing carts and reviewing medication supply with Medication Aides three times a week to ensure medications are ordered when needed. Medications need to be re-ordered as indicated on the medication card. The Charge nurse/Medication Aide will review the order status in PCC under the residents MAR for medications needing to be reordered and reorder if needed. Notify the MD and DON immediately for any resident medications that will not be administered as ordered. The DON and ADON will be in-serviced by the regional nurse on 5/18/23 on pulling the electronic transmission report to show which medications have been reordered and the status of the pharmacy refilling the medication. The medical director was notified of med error and immediate jeopardy as of 5/17/2023. Monitoring The DON / designee will review the med administration audit report 5 days per week to ensure all meds are administered as ordered. Review of the med administration audit report will be a permanent process that will occur indefinitely. This report includes all resident medications. The DON/ADON/Designee will review the electronic transmission report 5 days per week for the status of re-ordered medications. This report shows if there is a new pharmacy order or reorder and the date/time it occurred. This will become a permanent process that will occur indefinitely. The DON/ADON/Designee will audit all resident medications twice per week to ensure a 5-7 day supply of medication are present and maintained. Auditing and monitoring will be a permanent process that will occur indefinitely. This report includes all resident medications. The QA committee will review the findings monthly x 3 months and make changes as needed. Verification of Plan of Removal was as follows: a. Reviewed in-service training initiated on 5/16/2023: the 5 rights of medication administration for all nurses and CMAs. b. Reporting to doctor, DON, and ADON any medication errors for all nurses and CMAs. c. Ordering medications for all nurses and CMAs. d. Seizure activity and documentation for all nurses. e. Electronic Transmission Report with inbound and outbound messages, clinical dashboard, integrated pharmacy alerts for DON and ADON. f. Reviewed monitoring tool for medication administration audits. Interviews conducted 5/18/2023 between 2:50 p.m. and 4:15 p.m. revealed LVNs D, E, G, and CMA F had received in-service training and were able to verbalize the 5 rights of medication administration, had knowledge and understanding of when and who needed to be notified in the event of a med error, the process of when and how to reorder medications, and who was responsible to do so. The DON was knowledgeable of the Electronic Transmission Report with inbound and outbound messages, clinical dashboard, integrated pharmacy alerts that she and the ADON would be responsible for. On 5/18/2023 at 4:20 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.