**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision.CNA A did not follow 2-person assist as stated on Resident #1's care plan when providing incontinent care and repositioning on two separate occasions on [DATE] at around 12:00am and 1:00am. On [DATE] at 3:30am CNA A found Resident #1 on the floor. Resident #1 was sent to the hospital and later expired on [DATE].An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:51pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These deficient practices could affect residents who require 2-person assist by placing them at risk of injuries and not receiving the appropriate level of assistance and care. The findings included: Record review of Resident #1's face sheet, dated [DATE], revealed the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: cerebral infarction (blocked blood flow to brain causing brain tissues damage), hemiplegia (paralysis or severe weakness to one side of body) and hemiparesis (weakness to one side of body) following unspecified cerebrovascular disease (conditions that affect blood flow to brain) affecting left non-dominant side. Cognitive communication deficit (difficulties in communication could be from cognitive impairment), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to brain), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Record review of Resident #1's quarterly MDS assessment, dated [DATE], revealed Resident #1 was rarely/never understood and indicated a BIMS should not be conducted. Resident #1 was coded as dependent for rolling left and right and toileting/hygiene. Record review of Resident #1's care plan with a closed date of [DATE] reflected Resident #1 was bed bound and required total x2 assist (2-person assistance) for bed mobility and toileting. Record review of Resident #1's task care record reflected CNA A turned and repositioned Resident #1 at 1:13 am on [DATE]. Record review of Resident #1's task care record reflected CNA A checked off that Resident #1 had a small bowel movement at 1:13 am on [DATE]. Observation of facility surveillance footage of Resident #1's hallway on [DATE] revealed CNA A had entered or exited Resident #1's room approximately 4 times between 12:00am and 3:26am for no more than roughly one minute at a time on video footage that was able to be reviewed without any instances of skipped footage. The video surveillance would at times skip forward and miss seconds to a minute of footage, 1 of the 4 times identified did not show CNA A entering Resident #1's room when the footage skipped roughly 45 seconds from 3:23am to 3:24am where CNA A was then seen exiting Resident #1's room. LVN B was noted to have entered Resident #1's room at 1:19am and exited by 1:20am. At 3:27am CNA A was seen on video footage taking an item from a linen cart into Resident #1's room, CNA A remained in Resident #1's room until approximately 3:39am a total of about 12 minutes when he then exited the room and proceed down the hall to the nurse's station and briefly spoke with LVN B and C before he was noted returning down Resident #1's hall. At time of CNA A seen walking back down the hall video surveillance then skipped forward about a minute to 3:41am where CNA A was seen entering Resident #1's room for about 10 seconds and then exited and proceeded down hall way to nurses station to call LVN B and C when all 3 staff members went to Resident #1's room, prior to this time, CNA A was not seen entering Resident #1's room with any other staff member.During an interview with Administrator on [DATE] at around 6:00pm stated the time stamp on the video surveillance footage was 10 minutes ahead or 10 minutes behind. During an interview on [DATE] at 6:18pm with LVN B who stated she called EMS at 3:32am as per the time stamp of the call on her phone, when compared to the video footage time stamp LVN B is seen running back to the nurse's station to make call at 3:42am indicating the time stamp on the video surveillance was 10 minutes ahead. Record review of Resident #1's nursing notes dated [DATE] at 3:45am written by LVN B stated an aide had reported they found Resident #1 on the floor and saw blood, LVN B and other charge nurse (LVN C) went to assess and identified a laceration to scalp and active bleeding, pressure was applied to stop bleeding until the paramedics arrived, vitals were taken, 3rd party on call service was called, hospice and responsible party for Resident #1 were made aware. Resident #1 received order to be sent out to emergency room. Record review of Resident #1's physician orders reflected an order dated [DATE] at 3:45am for her to be transferred to the emergency department. Record review of Resident #1 hospital records date [DATE] at 5:34am stated Resident #1 had a 12 cm scalp laceration to the right head extending from the forehead to the parietal region. Record review of Resident #1 hospital records reflected Resident #1 expired at the hospital on [DATE] at 10:34am. Record review of CNA A's undated statement about Resident #1 reflected he found Resident #1 on the floor while rounding between rooms and stated the last time he had changed her was around 12:00am when he changed her by himself. During an interview with CNA A on [DATE] at 2:58pm stated he worked on [DATE] and entered his shift about 10 minutes till 12:00am and worked until 6:00am. CNA A stated on [DATE] he worked with Resident #1. CNA A stated he entered Resident #1's room after 12:00am at some time close to 1:00am and stated at that time he checked if resident was wet or dry. CNA A stated she was dry and he repositioned her from supine (laying on back facing up) to her side and facing towards the door, CNA A stated he placed a wedge on Resident #1's back, used a blanket as a posey in the front of her body that had been placed under the fitted sheet, and placed a pillow between her legs. CNA A stated the air mattress Resident #1 had in place was working appropriately on [DATE]. CNA A stated he only moved her that one time when he repositioned her. CNA A stated he repositioned Resident #1 by himself and stated she should have been a 2 person assist and stated he did not use 2 people because he was not sure and stated he had done it on his own previously. CNA A stated he then went to check on Resident #1 at 3:30am and found her on the floor. CNA A stated he remembered entering Resident #1's room around 3:27am but stated he did not recall being in there for 13 minutes when checking her. CNA A stated he did have a linen cart with sheets and stated he may have taken some linen into Residents #1's room but he did not recall what time that was at. CNA A stated he did not recall going into Resident #1's room for 13 minutes or taking in linen to her room prior to finding her on the floor. CNA A denied Resident #1 falling while changing, repositioning or moving Resident #1. During a follow up interview with CNA A on [DATE] at 5:21pm stated Resident #1 was non verbal and mostly moaned or groaned and was unable to move herself. CNA A clarified that he had worked with Resident #1 on his own before with only 1 person assistance an stated nurses who he was unable to recall had seen him do so and had not told him anything. CNA A stated on [DATE] there were 2 other nurses and 2 other aides available to assist but he did not ask anyone for help. CNA A stated he had previously been trained and knew where to find a residents assistance level in their POC and Kardex and stated he did not know Resident #1 was a 2 person assist until later and thought she was a 1 person assist because he had provided 1 person assist in the past and no one had said much. CNA A stated he should have asked and checked the Resident #1's assistance levels. CNA A stated he had previously been trained prior to Resident #1's fall on Resident #1 being a 2 person assist. CNA A stated then stated that he had worked Resident #1 twice on [DATE], the first time around 12:00am when he repositioned her and checked if she was dry and then later around 1:00am he stated he thought that he had changed her. CNA A stated he took roughly 20 seconds to a minute to change Resident #1. CNA A stated he went to go see how Resident #1 was at around 3:00am or 3:30am when he found Resident #1 on the floor and went to call the nurses. CNA A stated Resident #1 was bleeding from her head and appeared in pain because she was grimacing. CNA A stated the facility policy was to use 2 people if a resident required 2 person assist, CNA A stated he did not follow the facility policy In this situation. CNA A stated using 1 person assist when a resident required 2 could negatively impact a resident because it would put a resident at risk for fall. During an interview with LVN B on [DATE] at 12:54pm LVN B stated she worked on [DATE] from 6:00pm till 6:00am and was the nurse for Resident #1 and worked with CNA A. LVN B stated CNA A did not ask her for any help and stated she did not assist CNA A with any care for Resident #1 on [DATE]. LVN B stated she went into Resident #1's room around 1:00am and to turn off her TV. LVN B stated at that time Resident #1 was positioned in the middle of the bed facing the door with a low bed. LVN B stated she did not see Resident #1 again until CNA A notified her that Resident #1 was on the floor at around 3:30am. LVN B stated CNA A told her he had just exited from resident room from across the hall when he entered Resident #1's room and saw her on the floor. LVN B stated Resident #1 was not verbal and only groaned. LVN B stated when she entered Resident #1's room she was on the floor flat on her back with the bed in a low position and the air mattress functioning and set appropriately. LVN B stated Resident #1 had a puddle of blood around her head and a cut. LVN B stated LVN C stayed to render help and LVN B ran to call 911 and get the paperwork ready. LVN B stated CNA A had stated he changed Resident #1 at around midnight by himself. LVN B stated Resident #1 required 2-person assistance and was unable to move on her own and would not have been able to roll herself off the bed. During a follow up interview with LVN B on [DATE] at 6:18pm stated she notified the administrator of Resident #1 fall and laceration at 3:50am after emergency medical services had taken her. LVN B stated she notified the Administrator that CNA A found Resident #1 On the floor during a round, and she had a laceration and was bleeding and was being sent to the hospital. LVN B clarified that the cut she saw on Resident #1 was on her forehead. LVN B stated the facility policy stated they had to provide 2-person assist If the residents required it. LVN B stated CNA A did not follow the facility policy in this situation. LVN B stated using 1 person assist for residents who required 2 could negatively impact residents due to residents potentially falling if there was no staff on the other side of the bed to catch them. During an interview with LVN C on [DATE] at 11:45am stated Resident #1 was not her resident on [DATE] during her shift from 6:00pm - 6:00am. LVN C stated CNA A had said he changed Resident #1 at least once prior to the fall but stated he did not say at what time. LVN B stated CNA A stated he had changed Resident #1 by himself. LVN B stated he did not help CNA A with Resident #1 on [DATE]. LVN B stated CNA A notified her and another nurse that he had seen Resident #1's feet on the floor and realized she was not on the bed and then went to notify them. During a follow up interview with LVN C on [DATE] at 7:02pm stated when she was notified of Resident #1 was found on the floor she was in supine position (on her back) and there was a pool of blood and she saw an injury to her head on the right side and looked like her skin pulled back and placed pressure on her head while LVN B called 911 and the notifications. LVN C stated Resident #1 was awake and conscious. During an interview with the Administrator on [DATE] at around 8:07pm stated the DON was on leave and out of the country and did not currently have cell phone service to receive calls. The Administrator said that on [DATE] at around 3:30am CNA A found Resident#1 on the floor while completing his round and notified LVN B and C. The Administrator stated through the facility investigation which included an interview and statement from CNA A, the facility identified that CNA A did not have any assistance from other staff when he provided care to Resident #1. The Administrator stated Resident #1 required 2 person assistance for all ADLs, bed mobility, repositioning and when being changed and was not able to move herself. As per Administrator CNA A stated he knew Resident #1 was a 2 person assist and stated he had been trained on the POC (plan of care) but still decided to provide care by himself and said he could do it himself. The Administrator stated there were 2 other aides and 2 other nurses that were available to assist CNA A during that shift at that station and in total 10 other staff in the facility that could have helped. The Administrator stated CNA A stated at around 1:00AM or 1:15am on [DATE] he went into resident #1's room to provide incontinent care and reposition Resident #1 and left her in the center of the bed facing the door. The Administrator stated CNA A had been previously trained over the POC and Kardex and where to find residents levels of assistance. The Administrator stated CNA A did not mentioned anything about dropping Resident #1 or working with her when she fell. The Administrator all staff including CNA A had been trained previously to Resident #1 requiring 2 person assistance. The Administrator stated she was thinking Resident #1's fall occurred due to body alignment and stated she was thinking Resident #1 was possibly not centered in the bed. The Administrator stated the facilities policy regarding following a resident's plan of care when they required 2 person assist and stated therapy evaluation will determine if a residents were 1 or 2 person and in return the plan of care will show the level of care needed and if staff did not follow the plan of care for safety then it was an immediate termination for the staff member. The Administrator stated CNA A did not follow this policy in this situation. The Administrator providing residents who required 2 person assistance with only 1 person assistance could impact residents safety and cause injury. During an interview on [DATE] at 5:50pm the Administrator stated she was the abuse coordinator and responsible for reporting any incident or allegation of abuse, neglect or exploitation to state agencies. The Administrator stated she completed annual training over reporting requirements along with going over provider letters or trainings from an online training program the facility used and stated staff was trained over abuse and neglect frequently and stated that training was provided to her by the Regional Director of Operations and to the staff by the DON or one of the ADONs. The Administrator confirmed that Resident #1 was found on the floor with a laceration to her head on [DATE] and was unable to explain what happened and was not witnessed and required to be sent out to the hospital for treatment. The Administrator stated she received a text from LVN B on [DATE] at around 3:40am or 3:50am that stated Resident #1 had an unwitnessed fall, laceration with active bleeding with first aide rendered, notifications made to a 3rd party on call service used by facility, 911 activated, doctor and responsible part of Resident #1 were notified. The Administrator stated she did see the message about 5am. The Administrator stated around 12:00pm on [DATE] she was notified by family of Resident #1 that she had expired. The Administrator stated incidents like this was to be reported with 2 hours to HHSC and she stated she reported when she found out that Resident #2 had expired and stated she did not report with into two hours of her unwitnessed fall because the severity of the laceration was not said and the incident report was not alarming or suspicious. The Administrator stated to ensure staff provided her with sufficient information and assessment of resident's incidents to allow her to determine reporting timeline she would ask questions, review the incident report and reach out for any updates on residents at the hospital. The Administrator stated the facility policy for reporting allegations and incidents abuse, neglect and exploitation referred to a provider letter but was unable to state which provider letter aside from stating it was the most recent one. The Administrator stated she did follow the facility policy in this situation and stated not appropriately reporting allegation or incidents of abuse, neglect and exploitation could negatively impact residents because their safety can be impacted and their residents safety was their priority. Record Review of a document titled, Termination Form and dated [DATE] reflected CNA A's termination date as [DATE].Record review of facility Inservice training report dated [DATE] that stated staff must review all assigned plans of care to assure appropriate staff was in place prior to rendering care and staff had to be able to demonstrate how to access the plan of care, how to reach and what it meant and the importance of being complaint. Review of sign in attendance documentation reflected CNA A had completed this Inservice. Record review of facility ADL care policy provided and with an origination date of [DATE] did not mention any verbiage related to following resident care plan when 2-person assistance is required. During an interview on [DATE] at 4:18pm the Administrator stated she reached out to cooperate and was told that their ADL policy was the care plan policy. Record review of facility Inservice training report dated [DATE] that covered allegations of abuse, neglect and exploitation to be reported immediately and no later than 2 hours and other incidents that are reportable to be reported immediately but not later than 24 hours to HHSC. Review of sign in attendance sheet for Inservice reflected the Administrator had completed this Inservice. Record review of facility policy titled, Policy and Procedure: Abuse, Neglect and Exploitation with an revised date of [DATE] stated under section, IV. Identification of Abuse, Neglect, and Exploitation.B. Possible indicators of abuse include, but are not limited to.3. Physical injury of a resident, of unknown source.8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing turning & repositioning VII. Reporting/Response A. The facility reports abuse and abuse allegations that include:1. Reporting allegations involving staff to-resident abuse, resident-to resident altercations involving allegations of abuse, injuries of unknown source, misappropriation of resident property exploitation, and mistreatment.2. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves Abuse (with or without bodily injury)b. An Incident that results in serious bodily injury and that involves any of the following: Neglect Exploitation Mistreatment Injuries of unknown source Misappropriation of resident propertyC. Not later than 24 hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury but that involves any of the following: Neglect Exploitation A missing resident Misappropriation of resident property Drug thief Fire Emergency situation that pose a threat to resident health and safety A death under unusual circumstances Communicable disease situation that pose a threat to resident health and safety. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:51pm. The administrator was notified. The Administrator was provided with the IJ template on [DATE] at 5:46pm The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] at 1:25 pm: Tag Cited: F-689Issue Cited: Free of Accidents/Hazards/Supervision#5 1. Immediate Action Taken On [DATE] Resident #1 had an unwitnessed fall sustained a laceration @ 0330am, first aid rendered was sent to the hospital Facility initiated investigation Reported to Texas Health and Human Services Intake#1021508, physician and RP, [local police department] CNA A suspended on 7/7 and terminated [DATE]. 2. Identification of Residents Affected or Likely to be Affected: On [DATE] the DON/Designee completed an audit on all residents identified as two person-assist; 64 resident were identified in the facility. On [DATE] the DON/Designee completed an audit on all residents identified with air mattress, 46 residents were identified in the facility 3. Actions to Prevent Occurrence/Recurrence: DON reviewed staffing levels on [DATE] to ensure adequate staffing; no changes required DON/designee conducted audit on [DATE] @6:00pm reviewed all residents requiring two-person assist; point of care and care plan reviewed for accuracy DON/designee conducted audit on [DATE] @6:00pm identified all residents on air mattress, and review orders against setting for accuracy. On [DATE] DON/designee in-service all staff on Abuse/Neglect Policy completed on [DATE] by 5:00pm, Any new hires by the facility will receive education upon hire. On [DATE] DON/designee in-service all staff on Fall Management completed on [DATE] by 5:00pm, Any new hires by the facility will receive education upon hire. On [DATE] DON/designee in-service all direct care staff on resident Point of Care completed on [DATE]. Any new hires by the facility will receive education upon hire. On [DATE] DON/designee Performed two-person skill validation with return demonstration on all direct care staff, completed on [DATE]. Any new hires by the facility will receive skill validation training Charge nurses with monitoring tool will monitor the point of care for ADL assistance and ensure the CNAs are adhering to the residents' point of care every shift to ensure the designated level of care for each resident is accurate per point of care. Any discrepancies will be corrected immediately, reported to the DON/designee and re-education as needed. S Charge nurse will print out Kardex daily and review with CNAS Charge nurse will conduct walking rounds with CNA and acknowledge S Documented on monitoring sheet, any discrepancies will be reported immediately to DON/ADON DON/designee will review charge nurse monitoring form daily 5 times a week. All findings will be reviewed in morning meeting with IDT and revisions to plan may be made as necessary. DON/designee will do monitoring in random shifts for 3 residents 5x week to ensure the designated level of care for each resident is accurate per point of care. Ad Hoc QAPI conducted on [DATE] @ 2:00pm with Medical Director to review and discuss plan to sustain compliance. 0n [DATE] at 7:30 pm the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy's the facility received related to resident free of accident/hazards/supervision and review plan to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ______[DATE]__________ The state surveyor confirmed the facility's Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy that included: Record Review on [DATE] of facilities immediate actions taken in response to Resident #1's fall reflected LVN B documented Resident #1's fall on a nursing note dated [DATE] which included her being notified of fall, how Resident #1 presented when observed by nurse, vitals, notifications made and orders received. Note dated [DATE] from an on call provider reflected Resident #1's fall and their orders to send Resident #1 out to the emergency department. A post fall evaluation was completed in response to Resident #1's fall with an effective date of [DATE]. Facility initiated neuro checks on [DATE] at 3:30am. Facility generated incident report dated [DATE] that included summary of Resident #1's incident, immediate actions taken, pain scale which reflected a pain level of 7, and the notifications made. Facility initiated investigation into incident that included staff statements, resident skin assessments, and report made to HHSC, police department was contacted however report for incident was not yet completed. Documentation of termination of CNA A's employment reviewed and reflected he was terminated on [DATE]. Record review of staffing list for [DATE] was signed as reviewed by ADON D and identified a total of 2 nurses and 3 aides working on station 1 where Resident #1 was located and 3 nurses and 3 aides working in station 2 for a total of 11 staff that were scheduled and worked on [DATE] at time of Resident #1's fall. Record review of facility audit that identified a total of 64 residents who required 2 person assistance was signed as verified on [DATE]. Record review of facility audit of residents with air mattress included review of order listing report document with list of residents with mattress orders in place with a date of [DATE]. A total of 46 resident were noted to be identified with air mattress orders in place. Record review of staff training dated from [DATE] to [DATE] reflected staff had been trained over abuse and neglect, fall management, POC, with nursing staff completing a 2 person skills validation with return demonstration. On [DATE] and [DATE] a total of 10 aides, 8 LVNs, from all shifts 1 ADON and Administrator were interviewed with all staff stating they had recently received training with in the past few day that covered the abuse and neglect policy that included what to report and who to report, the kinds of abuse and the timeline for reporting and fall management that included how to prevent falls, what to do when they occur, who to notify and incident reports, use of wedges, bolsters, mats and low beds and using 2 persons. Staff had been trained over the plan of care and where to find it and how to where to find resident assistant levels and identify how many staff are required for assistance. Nursing staff had also completed a 2 person skill validation that required them to reposition and move a resident in bed with use of 2 people and be checked off by leadership staff. Staff were aware of new procedure of charg e nurses reviewing resident Kardex with aides at start of all shifts and complete walking rounds with the aides to ensure they understand the level of assistance required for residents care. Nursing staff was aware of aides signing on the Kardex to indicate they understood and charge nurses filling out the monitoring sheet that also included if aides required more education and notifying the DON or an ADON if a any discrepancies were noted. to All staff interviewed were able to recall training and procedures they were educated on. ADON E along with charge nurses were aware of review of monitoring sheets daily during the morning meetings, with ADON E stating her and ADON D were to separately monitoring 3 residents 5 times a week on a random shift to ensure residents level of care is accurate. Record review and observation completed by survey reflected 6 sampled residents, Residents #2, #3, #4, #5, #6 and #7 had information on their care plan and Kardex indicating their level of care (2 person assistance) and had orders in place for air mattress which were observed to be on appropriate setting when compared to orders that were in place. The Administrator was informed the Immediate Jeopardy (IJ) was removed on [DATE] at 7:59pm. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status due to medication error for one (Resident #7) of three residents reviewed for resident rights. The facility failed to notify Resident #7's physician in a timely manner when Resident #7 was administered 1 ml of Morphine Sulfate (concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) instead physician's order of 0.1ml morphine sulfate on 01/10/2023. An Immediate Jeopardy was identified on 08/11/2023. The Immediate Jeopardy template was provided to the facility Administrator on 08/11/2023 at 7:23 PM. While the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m., the facility remained out of compliance at a scope of isolated and severity level of actual harm because of the facility's need to complete in-servicing and monitoring interventions. This failure could place residents at risk of not receiving appropriate care and interventions and/or death. The finding included: Record review of Resident #7's admission Record dated 12/12/2022 indicated Resident #7 was an [AGE] year-old female and was admitted to facility on 09/28/2022 with the following diagnosis: of encephalopathy (a broad term for any brain disease that alters brain function or structure), COVID-19, lobar pneumonia (acute exudative inflammation of the entire lobe), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), gastro-esophageal reflux disease without esophagitis (a type of Gerd that does not involve inflammation of the esophagus), spinal stenosis, cervical region (narrowing of the spinal canal), dependence on supplemental oxygen, depression, acute respiratory failure with hypercapnia, type 2 diabetes mellitus without complications, hyperlipidemia (elevated levels of lipids like cholesterol and triglycerides in the blood), chronic pain syndrome, hypertension, chronic ischemic heart disease ( heart problems caused by narrowed heart arteries), peripheral vascular disease, constipation, secondary kyphosis (fracture in one or more vertebral bodies) spondylosis (age related wear and tear of the spinal disks), adult failure to thrive, and history of falls. Record review of Resident #7's MDS assessment, dated 12/15/2022 indicated: -BIMS score was 15 (cognitively status independent, decisions consistent/reasonable) -Coded as being under hospice care -required limited assistance with one person assist with bed mobility, transfer, walk-in corridor, walk-in-room, and toilet use -required supervised with one person assist for locomotion on unit, locomotion off unit, dressing and personal hygiene -was independent with setup help only for feeding -history of falls prior to admission/entry or re-entry Record review of Resident #7's comprehensive care plan dated 09/29/2022 revealed: Resident #7 was under hospice Focus: Resident #7 has a terminal illness and is receiving hospice or palliative care. During the end-of-life process weight loss, skin breakdown, dehydration, fecal impaction, and the gradual o or rapid loss of the ability to move may be unavoidable. Date initiated: 01/08/2023 Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of interventions through the next review. Date initiated: 01/08/2023 Interventions: Coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Date initiated 01/08/2023; Assist with ADL's and provide comfort measures as needed. Date initiated 01/08/2023; Monitor for abnormal weight loss, poor appetite, and skin breakdown. Report abnormals to the physician as noted. Date initiated 01/08/2023; Monitor for signs and symptoms of increased pain, discomfort-give medications and treatments as ordered and monitor for relief. Date initiated 01/08/2023. Record review of Resident #7's comprehensive care plan dated 09/29/2022 revealed Morphine Sulphate (concentrate) Oral Solution 100 mg/5 ml (morphine sulfate) was not care planned. Record review of Resident #7's eMAR for January 2023 revealed: Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine Sulphate) Give 0.1 ml by mouth every 1 hours as needed for severe pain 7-10. Start date-01/09/2023 16:01 and discontinue date-01/11/2023 08:22. Further review of eMAR indicated Resident #7 did not receive Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine sulfate) from January 09, 2023, through January 11, 2023. Physician order viewed under orders. Record review of Resident #7's progress note dated 01/09/2023 at 16:04 (04:04 p.m.) revealed Note: This order is outside of the recommended dose or frequency. Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain. Record review of Resident #7's progress note dated 01/10/2023 at 14:00 (04:00 p.m.) revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Record review of Resident #7's progress note date 01/10/2023 at 18:47 revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Both progress notes dated 01/10/2023 at 14:00 and 18:47 had been struck off. Record review of Resident #7's comprehensive care plan and progress notes indicated no notes from facility why Resident #7 was sent to the hospital. Record review of the hospital records for Resident #7, dated 01/10/2023 at 18:23 (06:23 p.m.) revealed the following: Patient is an 87 y/o (year old) F (female) with PMH (past medical history) of DM (diabetes mellitus), CVD (cardiovascular disease) with no residual effect per son who presents as trauma admission s/p (status post) unwitnessed GLF (ground level fall) at 17:00 on 01/10/2023. Per family member patient lives in a nursing facility and had a fall from her wheelchair as she was trying to get up. No LOC (loss of consciousness). Patient at baseline is non ambulatory; uses a wheelchair. On presentation, patient difficult to awaken, sternal rub elicits limited response. History limited due to patient's status; patient family member present at bedside is also unclear of history. Physical Examination: General: minimally responsive; open eyes minimally after sternal rub. Eye: unable to examine HENT: V shaped laceration on the left side of forehead Respiratory: Lungs are clear to auscultation, respirations are non-labored Cardiovascular: Normal rate, regular rhythm, good pulse equal in all extremities Gastrointestinal: soft, non-tender, non-distended Musculoskeletal: unable to examine Integumentary: decubitus ulcer in sacral area and heal, present on admission Neurologic: minimally responsive to sternal rub Cognition and Speech: unable to examine Psychiatric: unable to examine. Impression and Plan Patient non arousable initially on exam. Head CT on arrival shows 0.4 subdural hematoma, repeat CT head recommended in the AM. Hospital [NAME]: Heat CT (cat scan) on arrival shows 0.4 mm subdural hematoma. Dr. consulted recommended repeat CT (cat scan) head the following morning which was stable with 4 mm subdural hematoma. No intervention per neurosurgery. Patient is complaining of neck pain with history of cervical stenosis, previous workup negative for acute cardiac pathology. Patient's family requested application to new SNF (skilled nursing facility), during her stay patient had no acute events. Patient is ready for discharge. Operative Report: Consent: signed by patient Location: forehead Preparation and technique: 3 sutures placed Interview on 08/10/2023 at 5:55 p.m. via telephone with LVN A, revealed on 01/10/2023 at about 4:00 p.m. Staff F came to the nurse's station where she was and advised her Resident #7 was requesting pain medication due to having neck pain. Staff E said she told Staff F Resident #7 had recently been prescribed Morphine for pain. LVN A said she and RN A walked over to Resident #7's room because she wanted to make sure Resident #7 was alert and I just wanted to observe her to make sure she was in pain. LVN A said she had been in Resident #7's room a short time before and she did not complain of any pain. Upon entering Resident #7's room, Resident #7 was observed sitting in her wheelchair next to her bed. LVN A said Resident #7 did complain of neck pain and requested pain medication. At that time LVN A said she and RN A went outside to the hall and unlocked the med cart and pulled the Morphine box out and compared the label on the box with the order which indicated to give 0.1 ml as needed for pain every 1 hour. LVN A said after she and RN A verified the name, dosage, and route she went back to Resident #7's room to transfer her to bed while RN A stayed in the hall preparing the medication. LVN A said she transferred Resident #7 back to bed and advised her not to get up and if she needed anything to make sure to press the call light. Soon after that RN A came into Resident #7's room and administered Morphine. LVN A said RN A held up the syringe, showed it to her, and asked if it was ok to administer the Morphine, LVN A said, I didn't physically look at the syringe, but I said yes, and RN A administered the Morphine orally. LVN A said we both left back to the nurse's station and immediately RN A said she thought she had given Resident #7 the wrong dose of Morphine. At that point, LVN A replied, what do you mean RN A repeated I gave Resident #7 the wrong dose. LVN A said she immediately walked over to the med cart unlocked it and pulled the Morphine box out of the narc box to check the syringe. LVN A said after Morphine was given to a resident #7, the syringe was placed in a red plastic bag and placed back in the manufacture's box along with the Morphine. LVN A said when she checked the manufacture's box the syringe was not there. LVN A asked RN A where she had left the syringe and her response was I think I left it in Resident #7's room. LVN A said she went to Resident #7's room and found the syringe in a plastic bag on top of the dresser. At that point, RN A picked up the syringe and pointed to the 1.0 ml and told LVN A that's how much I gave her. LVN A said the facility has no protocol on how to manage medication errors, she said what she did after learning of the medication error was what she learned in nursing school. LVN A said she had been working at this facility for about 5 years and was trained on medication pass when hired. LVN A said she immediately went to check on Resident #7 and found her to be alert, not in respiratory distress and still lying-in bed. LVN A said, I don't remember if RN F or I notified hospice nurse, DON, and family member but they were notified immediately of the medication error. LVN A said I went to check on Resident #7 couple more times, I checked her breathing and was not in distress and was alert. LVN A said she does not remember the exact times she checked on Resident #7's saying, it's been a while. LVN A said between 5:30 p.m. and 5:45 p.m., a CNA was walking by Resident #7's room and noticed her laying on her left side on the floor. CNA called for help and LVN A ran to assist her. LVN A said Resident #7 was right by the door laying on her left side, bleeding from her forehead and had a bump on top of her scalp. LVN A said Resident #7 told her she managed to get out of bed, sit herself on her wheelchair when she tried reaching for something and fell. LVN A said she asked Resident #7 why she had gotten out of bed, and she replied, you know I'm stubborn. LVN A said she called Resident #7's doctor to inform of fall and was given instruction to send Resident #7 to the hospital to be evaluated. LVN A was asked if she notified Resident #7's doctor of the morphine dose error and she said yes adding I also notified the hospital when I called to let them know we were sending Resident #7 to the ER due to the fall. LVN A said Resident #7 was sent to the hospital due to the fall and not to the Morphine medication error. LVN A said Resident #7 had a history of falling and had received stiches on her head before due to the falls she had sustained since being admitted . LVN A said she made an incident report related to the medication error and the fall Resident #7 sustained on 01/10/2023. Surveyor asked LVN A how a medication error of Morphine negatively affect Resident #7 she replied to the most serious side effect could be respiratory distress. LVN A said the next day (01/11/2023) the DON and Administrator provided both she and RN A an in-service training on medication errors, were counseled individually and suspended for 3 days pending an investigation. Surveyor asked LVN A if RN A had given an explanation as to why she gave the wrong dose and she said RN A told her that in her previous job it was customary to give 1.0 of morphine so she figured it was the same at this facility. Interview via telephone on 08/11/2023 at 9:40 a.m., Primary Care physician (PCP) said he was not informed of Resident #7's morphine medication error. He said he wanted to make sure we understood this was the first time he was informed. The PCP said if he had been informed of the morphine medication error that would have unleashed a whole new protocol. Surveyor asked what he would have instructed the nurse to do, he replied, there would have been two possible responses. If resident was not experiencing respiratory distress, pulse was within range, she was cognitively aware, and heart rate was not abnormal, I would have instructed the nurse to observe the resident continuously (he did not say how long because everyone is different), resident did not need to be sent to the hospital because at that point because resident was stable. If the resident were experiencing respiratory distress, pulse was not within range, was not cognitively aware, and heart rate was abnormal, he would have instructed the nurse to administer Narcan and sent to hospital immediately. The PCP said Resident #7 received 10 times her prescribed order of morphine. PCP said 1.0 is the max dose of morphine and not deadly for a hospice resident because eventually they will require a higher dose. The PCP said Resident #7 still needed to be monitored for any adverse effect. Interview via telephone on 08/11/2023 at 10:30 a.m., The Hospice DON said Resident #7 was placed on hospice due to respiratory failure. The Hospice DON said facility called hospice at 09:32 p.m. on 01/10/2023. to inform them Resident#7 suffered a fall and sent to the hospital due to sustaining a hematoma to her forehead. The Hospice DON said on 01/11/2023 at 11:15 a.m. Facility's DON called them and advised of the morphine medication error. The Hospice DON said facility's DON said the syringes that came in the manufacture's box of the morphine medication did not have numbers only lines and that could have caused RN A to administer the wrong dosage of morphine to Resident #7. The Hospice DON said the medication/syringe was delivered by the pharmacy and it was considered a multi-use syringe. The Hospice DON said as a correction plan the hospice company delivered 10 to 15 syringes with numbers to avoid another medication error. The Hospice DON said if the facility had called immediately after the morphine medication error, she would have sent the hospice RN to the facility to assess Resident #7. The Hospice DON said she would have also instructed hospice RN to check her level of consciousness more frequent, her vitals for hypertension and fall precautions for at least 2 hours after medication error. The Hospice DON said Narcan would have been ordered depending how Resident #7 looked. Interview via telephone on 08/11/2023 at 11:00 a.m. The Hospice DON called back to say she had spoken to the previous acting hospice DON (at time of incident) who had clarified the first-time facility's DON had reported morphine medication error was on 01/11/2023. The Hospice DON also verified they had notified Resident #7's primary physician of her fall on 01/10/2023 at 9:30 p.m. Interview on 08/11/2023 at 11:15 a.m., LVN A said she had struck out Morphine entry on progress notes at 18:47 on PCC because she was not the one who had administered the morphine to Resident #7. Interview via telephone on 08/11/2023 at 12:50 p.m., RN A said on January 10, 2023, at approximately 4:00 p.m. while working under the supervision of Staff E (as it was her first day on the floor since being hired) she walked into Resident #7's room to check on her. RN A said Resident #7 complained of neck pain and requested pain medication. She immediately went looking for LVN A and found her in the nurse's station. She informed LVN A Resident #7 was requesting pain medication due to neck pain. RN A said she was told by LVN A Resident #7 was under hospice care and had a PRN (as needed) order of Morphine. RN A said she proceeded to the medication cart to prepare the syringe with the morphine solution. RN A said after she prepared the syringe with the morphine solution, she went looking for LVN A. RN A said she found LVN A in the medication storage room and appeared to be talking to someone on the phone because she had an ear pod in one ear. RN A said she signaled LVN A though the glass window to come out. RN A said LVN A opened the door without coming out and at that time they both checked the Morphine order with the label, name, dose, route, and I showed her the syringe with the morphine solution, and she nodded yes, she gave me a thumbs up. RN A said she then proceeded to Resident #7's room to administer the morphine. RN A said she first educated Resident #7 on the medication she was going to receive and transferred her back to her bed and administered the Morphine oral solution. RN A said she went to check on Resident #7 after 30 minutes or 1 hour (was not sure on the time) and Resident #7 was good, being her normal self. RN A said, we did our thing throughout our shift and around 5 or 6 p.m. LVN A calls out for help because Resident #7 had fallen and had a wound on her forehead. RN A said she stayed with Resident #7 while LVN A went to call 911. RN A said Resident was found between her bed and bathroom. RN A said she discovered the morphine medication error at about 6:30 p.m. when she was looking back at the eMAR and discovered I have given more than I should. RN A said she immediately informed LVN A but does not remember what her response was. RN A said, I texted DON at 6:31 p.m. telling her LVN A and I wanted to meet with her tomorrow to review possible med error. RN A said she texted DON because it was after working hours and DON was no longer at facility. As per RN A, DON responded back via text at 7:00 p.m. telling her Yes, please do so. RN A said Resident #7 had already been discharged to the hospital by the time she discovered the morphine medication error. RN A said sometime before the end of her shift LVN A told her We could have fixed it RN A reply to LVN A was there's no fixing, I gave what I gave. Surveyor asked RN A if she knew what LVN A meant by that and she said, to put 0.1 ml in the narc sheet even though I had given 1.0 ml of morphine. RN A said the next morning, DON met with both and them together and individually. She said they also had a general training with all nurses to make sure all nurses were doing their job. RN A said she received training on how to read eMAR and was not sure on the topics of other trainings received after med error incident. She said she and LVN A were suspended pending the outcome of the investigation. Surveyor asked RN A how Resident #7 could have been negatively impacted by receiving 1.0 ml of morphine sulfate instead of the ordered 0.1 ml, she said her breathing distress and high blood pressure. Staff F said 1.0 ml of morphine sulfate was appropriate for hospice patients but there must have been a reason Resident # 7's doctor had prescribed 0.1 ml of morphine sulfate. RN A said she decided to voluntarily quit her job as a registered nurse at the facility because she was told by someone LVN A had written a statement saying she had never shown her the syringe. RN A said she believed they would take LVN's statement over her since she had just been hired. RN A also said it was not a healthy environment and did not feel comfortable working at the facility. LVN A said she took a picture of the syringe used to administer the morphine sulphate to Resident #7 Interview via telephone on 08/11/2023 at 11:20 a.m. The Medical Director said he was informed of Resident #7's medication error by the facility's nurse on duty (did not have nurse's name) on 01/11/2023 and was not sure of the time either. The Medical Director said he and the rest of the QAPI team discussed medication error on 02/23/2023. The Medical Director said during the meeting they checked narcotic orders for all residents. The Medical Director was asked how Morphine medication error could negatively impacted Resident #7 and his response was she could have suffered neurological sedation, respiratory depression or excessive sedation but added Resident #7 did not have any negative effects. The Medical Director said if Resident #7 had suffered any side effects he would have ordered Narcan and sent to the hospital immediately. The Medical Director emphasized he was available to the facility 24/7 and facility did not notify him immediately. Interview on 08/11/2023 at 3:00 p.m., The DON said she expects all her nurses to inform her immediately in case of a medication error. She said if she was not at facility (after working hours) she expects a call from them immediately. The DON said she will ask the nurse what medication was given, the dosage and the correct dosage and depending on what they tell her, she would instruct them to either monitor or send to hospital. The DON said she immediately notifies resident's primary physician, family representative, medical director, and administrator of the medication error. The DON said after resident was cared for, she would complete the medication error report, start an investigation, re-educate staff and report to HHSC. The DON said the medication error was discovered after Resident #7 was discharged to the hospital due to sustaining an unwitnessed fall. The DON said Resident #7 had a history of falls and was non-compliant. The DON said she notified Resident # 7's primary doctor and hospice immediately of the fall but was not sure if she informed them of the medication error on the same day. The DON said the fall or medication error was not care planned because Resident #7 did not go back to facility after being discharged from hospital. Interview on 08/11/2023 at 3:30 p.m., The Administrator said facility's policy regarding medication error was for the nurses to let the DON know immediately after discovering a medication error was occurred. The Administrator said depending on how the resident was feeling, DON will instruct of appropriate action. The Administrator said it was the DON's responsibility to inform her of any medication errors immediately after being notified of one. The Administrator was asked how a morphine medication error could negatively affect Resident #7; her response was I don't know how to answer that question. Observation on 08/11/2023 at 1:41 p.m. RN A texted picture to surveyor and it showed a thin syringe with 4 lines (0.25 ml, 0.50 ml, 0.75 ml, and 1 ml). Record review of print out facility provided revealed five residents who were currently receiving Morphine. Record review sample audit conducted by DON showed five resident who were currently receiving Morphine. Record review of facility's policy Notification of Changes dated 01/10/2020 revealed: policy To provide guidance on when to communicate acute changes in status to MD, NP, and/responsible party. The facility will immediately inform the resident: consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: An accident resulting in injury to the resident that potentially requires physician intervention a significant change in the physical, mental or psychosocial status of the resident The need to significantly alter the resident's treatment The facility documents resident assessment(s), interventions, physician and family notification(s) on SBAR, Nurses Progress Notes, or Telephone Order Form (physician/family notice) as appropriate INTERACT IV may be used as a resource for evaluating resident change of condition for physician notification a. Immediate Physician Notification-the physician is notified immediately and should respond timely (within minutes), the Medical Director will be contacted before the resident will be sent for emergency room evaluation. b. Non-Immediate Physician Notification-the physician is notified and there should be a return call within the same day (worsening of symptoms use Immediate Physician Notification steps) The Administrator was informed the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m. The facility remained out of compliance at a severity level of 4 and a scope of J due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 1. Immediate Action Taken On 1/10/2023 resident # 7 was sent to the hospital and never returned to the facility. On 8/11/2023 DON/Designee completed an audit of all residents receiving Morphine in the center to verify that correct dose of Morphine was entered into the computer. This will be completed at 10:00 pm on 8/11/2023. On 8/11/2023 DON/Designee completed rounds on all residents to verify that a physician's notification was completed if a resident was identified with a change of condition. No residents were identified On 8/11/2023 DON/Designee started education with all licensed nurses on: o Policy on Medication Administration Guidelines that provide directions on the process of verifying labels for accuracy, verifying administration accuracy, verifying a focused assessment, administering the medication according to the physician's orders. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o Policy on Preventing/Detecting adverse consequences and Medications errors that provides directions to license nurses on immediate actions to take for a signification medication related error or adverse consequence: License nurse will notify the attending physician promptly of any significant error or adverse consequence License Nurse will Immplement (that is how it was written on POR) orders as directed by physician, and the resident is monitored closely for 24 to 72 hours or as directed. License Nurse will Communicate with other across shifts as indicated to alert staff of the need to monitor resident License Nurse will Complete an Incident report or Medication error form License Nurse to Report significant error to the DON DON will report significant error to Consultant Pharmacist This will be completed by 3:00 pm on 8/12/2023, and no licensed nurse will be allowed to work until they have received this education. The DON/Designee will be responsible for ensuring all license nurses understand and follow the guidelines for a significant error or adverse consequence. o Policy on Notification Change of Condition that provides directions on notifying family and physician when a change in a resident's conditions occurs. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o A skills competency on Medication Administration will be completed for all license nurses, validating proficiency in Medication Administration to validate medication administration competency and action to take if a significant error occurs. The DON/Designee will be responsible to ensure all license nurses are proficient in Medication Administration. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. 2. Identification of Residents Affected or Likely to be Affected: On 8/11/2023 DON/Designee started an audit review of all residents with new orders for the past 7 days to verify that correct dose of medications was entered into the computer correctly and no significant error occurred. This will be completed by 10:00 am on 8/12/203. 3. Actions to Prevent Occurrence/Recurrence: The DON/Designee daily will review all new medication orders during the morning meeting to verify all orders were entered correctly x 30 days. The DON/Designee daily will review the 24-hour report daily x 30 days to verify that any resident with a change of condition has physician and family notification. The DON/Designee will do random skills validation reviews with licensed nurses to verify medication administration competency and knowledge on what steps to take if a significant error occurs. The DON/Designee will be responsible to ensure all licenses nurses are proficient in Medication administration. On 8/11/2023 at 8:15pm the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy's the facility received related to residents free from significant medication error and Notification in change of condition and reviewed plan to sustain compliance. Verification: Started on 08/14/2023 at 8:30 a.m. and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 08/11/2023 and 08/13/2023: Observation on 08/16/2023, LVN C was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, RN B was observed during med pass by survey team, no discrepancies were observed. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Medication Administration Guidelines conducted by DON. 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 resident (R#4) of 7 residents reviewed for accidents, in that: Registered Nurse (RN E) and Certified Nurse Assistant (CNA D) failed to use a mechanical lift to transfer R#4 resulting in R#4 sustaining a left femoral fracture. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/03/2023 and ended on 03/09/2023. The facility corrected the non-compliance before the investigation began. Past Non-Compliance form sent to Administrator on 8/11/2023 at 7:23 PM. This failure could lead to the injury of residents that are transferred with a mechanical lift. The findings included: Record review of R #4's file reflected an [AGE] year-old female, with an original admission date of 02/09/2022. Diagnoses included: Osteoporosis (bones become weak and brittle), fracture of lower end of left femur (upper leg), Myalgia (muscle pain), fracture of left tibia (one of the two bones that connects the knee with the ankle bones), fracture of upper end of left humerus (upper arm), history of falling, Major Depressive Disorder, Epilepsy (disturbed nerve cell activity in the brain), Hemiplegia (paralysis of one side of the body), muscle wasting and atrophy, and muscle weakness. Record review of R #4's MDS assessment dated [DATE] reflected R#4 had a BIMS score of 15 (cognitively intact), required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, dressing, toilet use, and personal hygiene. The MDS also reflected R #4 required total dependence (full staff performance every time during entire 7-day period) with transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). R #4 required a two-person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. Record review of R #4's Care Plan dated 06/26/2023 reflected R #4 sustained alteration in musculoskeletal status related to left hand contracture-hemiplegia, left humerus fracture, left tibia fracture, and left femur fracture. R #4's care plan also reflected R #4 required total assistance x 2 with mechanical lift for transfers. Record Review reflected a progress note documented by RN E indicated on 03/03/2023 RN E and CNA D transferred R #4 from her wheelchair to the bed at approximately 5:54 PM. RN E and CNA D transferred R #4 without a mechanical lift. At the time of the transfer R #4 complained of pain to her left leg. An order for an x-ray was obtained. Further review of R #4 nurse's notes documented by RN F on 03/03/2023 at 8:30 PM reflected R #4 complained of pain and was sent out to the hospital for an x-ray approximately 2 hours later. The hospital x-ray revealed a distal fracture (break in the bone just above the knee) of the left femur. Record review of a progress note documented by RN F dated 03/04/2023 at 3:44 AM indicated R #4 stated she did not fall at any time. She stated that during the day shift, when she was being transferred from the bed, the mechanical lift was not working and that an attempt was made to transfer her. That was when she felt pain to her left lower extremity and immediately the attempt to transfer her was stopped. Nurse Practitioner was informed. Record review of the facility investigation dated 03/11/2023 revealed CNA D and RN E conducted a manual transfer due to the mechanical lift not operating. CNA D informed RN E of the mechanical lift not working, and RN E decided to do a manual transfer with CNA D. R #4 complained of pain to her left lag. RN F notified the doctor. X-ray results showed no fracture. R #4 continued to complain of pain. RN F notified the doctor. New order to send R #4 to the emergency room for evaluation and treatment. R #4 returned to the facility with no fracture and no hospital paperwork. RN F contacted the hospital and RN F was told R #4 had a left femoral fracture. New orders for pain medication. The Administrator interviewed R #4. R #4 stated she did not fall. R #4 stated she did not feel the incident was intentional and she gets good care at the facility. Investigation findings: Unfounded. Provider action taken post-investigation: RN E and CNA D were terminated. In-serviced all staff on abuse, neglect, fall management, Hoyer transfer, and plan of care. Transfer skill review. Interview with R #4 on 08/08/2023 at 11:45 AM revealed RN E and CNA D transferred her without using the mechanical lift, resulting in pain to her left leg when her left leg got stuck under her right leg during the transfer. She was checked by the nurse, sent to the hospital, and was diagnosed with a fracture. Interview with RN F (incoming shift nurse on 03/03/2023) on 08/10/2023 at 10:30 AM revealed R #4 was transferred by RN E and CNA D without a mechanical lift. RN F said he was not working when the transfer was done as he came into his shift after. RN F said he was working when R #4 was complaining of pain and R #4 was sent out the hospital due to pain to her left leg. It was determined R #4 obtained a fracture to her left leg. RN F said he recalled RN E being in a hurry to leave the facility during their shift change. RN F said the facility did trainings after this incident on how to properly use the mechanical lift. RN F said whenever there is an incident, the facility also does trainings on abuse/neglect, resident rights, and fall prevention, which the facility also did in this case. Interview with the Maintenance Supervisor on 08/10/2023 at 1:15 PM revealed the facility had a total of four mechanical lifts used for transfers. He added that the lifts were serviced every 3 months by the medical equipment provider. Maintenance Supervisor said there had not been any inoperable lifts or issues reported during the month of March 2023. Interview with the DON on 08/10/2023 at 3:40 PM revealed RN E and CNA D transferred R #4 without a mechanical lift, resulting in a femoral fracture to her left leg. The DON indicated that both staff were feeling pressured because at the time of transfer, R #4 was crying and wanting to get into bed, although the sling for the lift was not positioned well. The DON said CNA D and RN E did not use the lift because of the sling, not because the lift was not working, or the battery was not charged. The DON added that if there was any issue with the mechanical lift, whether it was the battery, lift, or sling, staff should get another mechanical lift, and not transfer the resident manually. The DON said staff should have followed R #4's care plan which indicated that she required a two-person transfer with the mechanical lift. The DON said R #4 had Osteopenia and brittle bones. The DON said failing to use the mechanical lift, placed R #4 at risk of obtaining injuries such as fractures, which was what ended up happening. The DON said all staff had been re-educated on the proper usage of mechanical lifts and transfers, on abuse/neglect, fall management, and resident rights. Interview with the Administrator on 08/11/2023 at 11:45 AM revealed RN E and CNA D transferred R #4 without a mechanical lift, resulting in a left femoral fracture. The Administrator said staff were trained on how to properly transfer residents. The Administrator said staff are trained when they are hired, annually, quarterly, and as needed. The Administrator said all staff were trained again after this incident with R #4. The Administrator added that there were several mechanical lifts, batteries, and extra slings that can be used at any time throughout the facility. The Administrator said the staff should have taken steps to follow R #4's care plan. The Administrator said RN E and CNA D were both terminated due to poor performance during the incident. The Administrator said to prevent an incident like that from reoccurring, they re-trained and re-educated all staff. The Administrator said staff have been in-serviced on mechanical lifts, transfers, resident rights, abuse/neglect, and fall management. The Administrator said they completed the in-services with all staff to ensure they knew where the batteries were located, how to properly use the sling, and the lift. The Administrator said the skills review for all staff were completed where staff demonstrated how to complete the skills. The Administrator said there have not been any similar situations or issues happen since then. Record Review of the Transfer of Residents Policy dated, 05/2012 revealed: -Transfers are defined as the act of moving a resident from one surface to another. The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident. Record Review of the Mechanical Lift Policy dated, 04/24/2014 revealed: -To move immobile residents from whom manual transfer poses potential for a resident injury. The following observations, interviews and record reviews were conducted by the survey team to ensure the Past Non-Compliance was corrected by 03/09/2023: -The following interviews were conducted by the Survey Team on 08/09/2023 and 08/10/2023: 2 CNA's, 2 LVN's, and 1 RN. -Staff acknowledged understanding of the topics they were in-serviced regarding the mechanical lift. -In-services reflect 57 staff were trained on the mechanical lift from 03/04/2023-03/09/2023. -Interviews with the DON, Administrator, and record review of the employee files reflected that CNA D and RN E were terminated due to poor performance during the incident with R #4. -On 08/17/2023, CNA N and CNA O were observed during a transfer with a mechanical lift. No discrepancies were noted. Interview with R #5 on 08/08/23 at 2:00 PM revealed she was doing fine. When asked if she had any issues with her care, R #5 shook her head no. When asked if she had any complaints or concerns, R #5 shook her head no. Other baseline questions were asked. However, R #5 would mumble or was clearly not understood. Interview with CNA A on 08/09/2023 at 1:55 PM revealed CNA A worked and transferred R #4 on the morning of 03/03/2023. CNA A said the mechanical lift was working on the morning of 03/03/2023 without issue. CNA A said if the mechanical lift was not working properly due to the battery or other reason, the staff should not do the transfer without the lift. CNA A said they should look for another battery or another lift. CNA A said R #4 required a two-person transfer with the mechanical lift. CNA A said the facility did trainings on how to use the lift properly, abuse/neglect, fall management, and rights. CNA A said the trainings are completed constantly, but the trainings were also completed after R #4 was injured. Interview with LVN C on 08/09/2023 at 3:00 PM revealed LVN C worked on 03/04/2023 when R #4 was requesting a police report be made for her injury. LVN C said she had informed the nurse and the nurse indicated to go ahead and call the police. LVN C said an officer came out to the facility and spoke to R #4 regarding her fracture. LVN C said she was not working on 03/03/2023 when R #4 got injured. LVN C said R #4 has always been a two person transfer with the mechanical lift. LVN C said the battery for the lift is charged in the supply room. LVN C said it is up to everyone to ensure the battery is charged. LVN C said there are extra lifts in the facility. LVN C said the facility did do trainings for abuse/neglect, rights, fall management, and how to use the lift properly. LVN C said the DON also did a skills review. LVN C said the trainings are done constantly but they were also done after R #4 was injured. Interview with LVN G on 08/10/2023 at 2:05 PM revealed LVN G said the extra battery for the lift is charging in the supply room next to the nurse's station. LVN G said when staff are hired, they are shown where the battery is kept. LVN G said if the lift is not working or if the battery is not charged, then the staff should tell the resident to wait a moment. LVN G said the staff can either look for another lift, change the battery, or charge the current battery a bit to use the lift. LVN G said the staff should not do the transfer without the lift if the resident requires it as they need to follow the care plan. LVN G said the facility constantly do trainings, but they were also done after R #4 was injured on 03/03/2023. LVN G said the trainings were on abuse/neglect, rights, fall management, and how to use the lift properly. LVN G said they were told about the extra batteries, extra slings, and how to ensure the lift is working before trying to use it. Interview with CNA H on 08/10/2023 at 2:35 PM revealed CNA H said R #4 requires the two-person transfer with the mechanical lift. CNA H said whenever she is going to use the mechanical lift, she ensures is has battery and that it is in good condition to use. CNA H said there is an extra battery in the supply room by the nurse's station. CNA H said if the mechanical lift is not working, the staff should look for another one. CNA H said the facility constantly does trainings with them to ensure they know how to do transfers or about abuse/neglect. CNA H said the DON did a training to review their skills after R #4 got hurt on 03/03/2023. CNA H said the DON also did trainings on abuse/neglect, rights, fall management, and how to use the lift properly. In an observation with R #17 on 08/10/23 at 5:35 PM. CNA N and CNA O knocked on the door, closed the door and washed their hands. CNA N closed the blinds. The CNAs explained to R #17 what they were going to do. CNA O turned him to place sling under his right side. CNA N turned him to place the sling under his left side. The CNAs kept asking R #17 if he is okay throughout process. CNA N moved the Hoyer lift into position and put on the brakes. CNA N lowered the mechanical lift. The CNAs connected the clips into place. CNA N lifted the mechanical lift using the remote. The CNAs comforted R #17 throughout, ensuring him he was okay. The CNAs moved the mechanical lift over with R #17 in the sling. The CNAs positioned the lift in front of the wheelchair and put the brakes on the lift. CNA N lowered the sling. The CNAs ensured R #17's feet, body, and wheelchair were in good position as the sling was lowered to the wheelchair. The CNAs unhooked the sling. CNA N moved the lift away. CNA O moved R #17 in the wheelchair and positioned him in front of the television. CNA O informed R #17 that it would be time for dinner soon. In an interview with R #17 on 08/10/23 at 5:46 PM, R #17 was asked what his name was and how was he doing. R #17 did not respond. R #17 was asked other baseline questions, but he did not respond. Record review reflected that from 03/04/2023-03/09/2023 all staff were in-serviced and re-educated on the proper usage of the mechanical lift, mechanical transfers-staff to use 2-person assist for mechanical transfers, staff to audit the mechanical lift prior to moving the machine, assure battery was charged, slings were matching, intact, and not torn. If the battery was not charged, staff were to find a new charged battery promptly. Plan of care-staff to follow the resident's plan of care at all times. The facility also in-serviced and re-educated all staff on resident rights, abuse/neglect, and fall management. A skills review was also completed for transfers including performance criteria of: properly cleaned hands prior to procedure, explained procedure to resident and encouraged resident to participate, provided for privacy as appropriate, used transfer device specified by care plan (Hoyer, slid board, etc.), used gait belt and obtained assistance as indicated by care plan, locked brakes or stabilized chair if not equipped with brakes, safely transferred resident using proper body mechanics, and type of transfer observed (chair to bed, bed to chair, chair to commode). Record review on 08/11/23 reflected there were 34 residents in the facility that use a mechanical lift, including R#4, R #5, and R #17. Record Review of Employee files reflected: RN E - Acknowledgement of abuse neglect and exploitation on 05/21/2021 Date of hire for RN E - 05/27/2021 CNA D - Acknowledgement of abuse neglect and exploitation 01/11/2023 Facility trainings done on 01/11/2023 for CNA D included: Reporting abuse, neglect and misappropriation of belongings, and Residents rights and responsibilities. Date of hire for CNA D - 01/13/2023

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 3 of 3 residents (Resident #8, Resident #9, and Resident # 10) being reviewed for pharmacy services. Facility did not ensure that narcotics were reconciled as being given from the resident's eMAR to the resident's narcotic reconciliation form on medication cart. This failure could place residents at risk of not receiving their narcotic medications and drug diversion. An Immediate Jeopardy was identified on 08/13/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 6:54 p.m. While the Immediate Jeopardy was removed on 08/17/2023 at 2:30 p.m., the facility remained out of compliance at no actual harm but potential for more than minimal harm due to no evidence of actual harm to any resident, because of the facility's need to complete in-servicing and auditing interventions. The findings included: Record review of Resident #8's admission Record indicated Resident #8 was an [AGE] year-old male admitted on [DATE] with the following diagnosis: Dementia with no behavioral disturbance, sequelae of cerebral infarction (residual effects or conditions produced after acute phase of an illness or injury has ended), other instability left wrist, chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes), presence of aortocoronary bypass graft (a surgical procedure used to treat coronary heart disease), dysphagia (difficulty swallowing), oropharyngeal phase (malignant cells form in the tissues of the oropharynx) nondisplaced fracture of the lateral epicondyle of left humerus, contracture left hand, vascular dementia (brain damaged caused by multiple strokes), psychotic disturbance, mood disturbance and anxiety, dysphasia following cerebral infarction, presence of automatic cardiac defibrillator, Unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), bipolar disorder, presence of cardiac pacemaker, epilepsy, and epileptic syndrome. Record review of Resident #8's MDS assessment, dated May 09, 2023, revealed: BIMS-left blank (severe impairment) requires extensive assistance with a two person assist with bed mobility requires limited assistance with a two person assist with transfer, dressing, eating and personal hygiene Record review of Resident #8's comprehensive care plan dated 03/08/2023 revealed: Focus: Resident #8 has a terminal illness and is receiving hospice or palliative care. Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of interventions through next review. Date initiated: 03/08/2023/Target date: 05/21/2023. Interventions: Monitor signs and symptoms of increased pain, discomfort-give medications and treat as ordered and monitor for relief. Record review of Resident #9's admission Record indicated Resident #9 is a [AGE] year old female, admitted on [DATE] with the following diagnosis: fracture of unspecified part of neck of right femur, osteoarthritis, scoliosis in thoracic region, acute kidney failure, history of falls, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, diverticulosis of large intestine, age-related physical debility, need for assistance with personal care, muscle wasting and atrophy, lack of coordination, personal history of covid-19, dysphagia (difficulty swallowing), alternating exotropia (outward turning eyes), edema, constipation, seasonal allergic rhinitis, major depressive disorder, hypertension, hypokalemia (low potassium), hyperlipidemia (elevated levels of lipids), anemia, hypothyroidism, gastro-esophageal reflux disease without esophagitis, presence of intraocular lens, vitreous membranes and strands, right eye. Record review of Resident #9's MDS record dated 07/18/2023 revealed: BIMS: 12 (cognitively intact) Requires extensive assistance with a two person assist for bed mobility Requires extensive assistance with a one person assist for dressing, toilet use, personal hygiene Record review of Resident #8's eMAR schedule for February 2023 revealed: Morphine Sulfate Oral Solution 20 MG/5ML (Morphine Sulfate), give 0.25 ml via G-tube every hour of sob (shortness of breath) and or severe pain. Start date: 02/03/2023 at 0945 D/C 08/12/2023 Record review of Resident #8's eMAR schedule for March-August 2023 revealed: Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) give 0.25 ml sublingually every 1 hours as needed for SOB (shortness of breath)/Severe Pain 7-10. Record review of Resident #8's orders for Lorazepam Oral Concentrate 2 MG/ML, give 2 MG/ML every 4 hours as needed for anxiety (sublingual). Record review of Resident #8's eMAR schedule for March 24,2023-June 12, 2023, revealed: Lorazepam Oral Concentrate 2 MG/ML. Give 1m by mouth every 4 hours as needed for anxiety, give sublingual. Record review of Resident #8's Controlled Substance Record of Administration (NARC sheet) and eMAR (electronic medication administration record) revealed: Record review of Resident #8's eMAR schedule for March 24,2023-June 12, 2023, revealed: Lorazepam Oral Concentrate 2 MG/ML. Give 1m by mouth every 4 hours as needed for anxiety, give sublingual. Record review of Resident #8's Controlled Substance Record of Administration (NARC sheet) and EMAR revealed: April 2023, 8 doses of Lorazepam 2 mg/ml were signed off on the Controlled Substance Record of Administration (NARC Sheet) and 15 were signed off on eMAR. May 2023, 4 doses of Lorazepam 2 mg/ml were signed off on the Controlled Substance Record of Administration (NARC Sheet) and 4 were signed off on eMAR. June 2023, 6 doses of Lorazepam 2 mg/ml were signed off on the Controlled Substance Record of Administration (NARC Sheet) and 3 were signed off on eMAR. From February 3, 2023, to August 12, 2023, 38 doses Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on the Controlled Substance Record of Administration (NARC sheet) while only 16 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on the Electronic Medication Administration Record (eMAR). From June 2023 to July 12, 2023, 8 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on Resident #9's Controlled Substance Record of Administration (NARC Sheet) while only 2 doses were signed off her Electronic Medication Administration Record (eMAR). Interview on 08/12/2023 at 10:30 p.m., DON and ADON were asked to reconcile Resident #8's order of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) with his Controlled Substance Record of Administration with his record of Electronic Medication Administration Record (eMAR) in front of surveyor. Both DON and ADON confirmed 38 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) were signed off on his Controlled Substance Record of Administration and only 16 doses were signed off on his Electronic Medication Administration Record (eMAR). Surveyor asked why the discrepancies and DON replied, I need to check with my nurses. Record review of Resident #9's eMAR schedule for June-July 2023 revealed: Morphine Sulfate (concentrate) Solution 20 MG/ML-give 0.25 ml sublingually every 4 hours as needed for Pain/SOB (shortness of breath). Start date-04/12/2023-Discontinue date-07/21/2023. Interview on 08/12/2023 at 10:40 p.m., DON and ADON were asked to reconcile Resident #9's order of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) with her Controlled Substance Record of Administration with her record of Electronic Medication Administration Record (eMAR) in front of surveyor. Both DON and ADON confirmed 8 doses of Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (morphine sulfate) while only 2 doses were signed off her Electronic Medication Administration Record (eMAR). Surveyor asked why the discrepancies and DON replied, I need to check with my nurses. Record review of Resident #10's admission Record dated 8/13/23 reflected [AGE] year-old male with an admission date of 7/7/23 and with diagnoses of Malignant Neoplasm of Vertebral Column (cancerous tumor of Spinal column), Malignant Neoplasm of Liver (cancerous tumor of liver) Not specified as Primary or Secondary, Malignant Neoplasm (cancerous tumor) Unspecified Part of Unspecified Bronchus or Lung, Malignant Neoplasm(cancerous tumor) of Pelvic Bones, Sacrum (triangular bone between hipbones of the pelvis in lower back) & Coccyx (small triangular bone at bottom of spinal column), Malignant Neoplasm(cancerous tumor) of Bone & Articular Cartilage (living tissue that lines the bony surface of joints) Unspecified, and Unspecified Cirrhosis (damage where healthy cells are replaced by scar tissue) of Liver. Record review of Resident #10's Clinical Physician Orders dated 8/11/23 reflected he had orders for -Oxycodone HCI Oral Tablet 10 MG 0.5 by mouth every 1 hour as needed start date: 7/7/23, d/c (discontinue) date: 7/12/23 -Oxycodone HCI Oral Tablet 10 MG 0.5 by mouth every 1 hour as needed start date: 7/15/23, d/c (discontinue) date: 7/21/23 -Oxycodone HCI Oral Tablet 10 MG .05 by mouth every 1 hour as needed start date: 7/10/23, d/c (discontinue) date: 7/14/23 -Oxycodone HCI Oral Tablet 10 MG give 10 MG by mouth every 1 hour as needed start date: 7/22/23, d/c (discontinue) date: 7/24/23 -Oxycodone HCI Oral Tablet 10 MG give 10 MG by mouth every 1 hour as needed start date: 7/21/23, d/c (discontinue) date: 7/21/23 -Record review of Resident #10's EMAR reflected on 7/10/23 at 0529 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/10/23 at 0530 and again at 2315 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/11/23 at 2342 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/11/23 at 0530 and again at 2342 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/12/23 at 2359 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/12/23 at 0109, 0402, and 2359 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/15/23 no dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/15/23 at 2320 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/17/23 10:31, 12:09 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/17/23 at 11:00, 12:00, 1400 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/19/23 1149 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/19/23 at 1149, 1430 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. -Record review of Resident #10's EMAR reflected on 7/22/23 0845 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. Record review of Resident #10's Controlled Substance Record of Administration reflected on 7/22/23 at 8:45 and 9:45 dose of oxycodone HCI oral concentrate 10 MG/0.5 ML .25 ml given by mouth. In an interview on 8/14/23 at 11:43 a.m. LVN M stated she does not recall it was human error and she did not have an excuse for not documenting on the EMAR of Resident #10's narcotic dosage. She said she knew she is supposed to document on both the EMAR and the narcotic sheet. In an interview on 8/14/23 at 1:21 p.m. LVN W stated she corrected her error and let the hospice nurse know. She said she filled out medication error paperwork when she failed to document on EMAR the dosage of narcotic given to Resident #10. She said she knew the procedure but was maybe in a rush that day. She could not remember. Record review of facility's policy on Drug Diversion Guideline dated 02/23/2017 revealed: The following recommendations are designed to reduce and limit drug diversions: Signing the narcotic shift count sheet means you are accepting responsibility for the controlled substances. Therefore, do not sign unless you are certain that all the controlled substances are present and have not been alternated/tempered with or altered in any way. Document usage both on MAR and narcotic count sheet as soon as possible after administration of medication Document administration of PRN's controlled substances on the MAR's including dose, date, time, route and effectiveness of medication Notify the DON and/or pharmacy consultant immediately in the event of suspected drug tampering or diversion Reporting Drug diversions or potential drug diversions are reported immediately to Administrator, DON, Pharmacy, State Agency, and Police for investigation. Record review of facility's policy on Clinical Document Guidelines dated 03/25/2014 revealed: Policy The patients clinical record provides a record of the health status, including observations, measurements, history and prognosis and serves as a primary document describing health care services provided to the patient Fundamental Information The clinical record is used by healthcare team to record, preserve and communicate the patient's progress and current treatment Procedure Clinical document entries should be objective, factual information and communication that pertain to the care of the patient for i.e., patient centered Clinical document entry should contain the month, day, year and the time the narrative is written Entries are signed by the person writing the narrative and include the first initial, last name and the title or credentials of the author Each healthcare team member must document his or her own clinical record entries An Immediate Jeopardy was identified on 08/13/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 6:54 p.m. A plan of removal was accepted on 08/13/2023 at 6:54 p.m. and indicated the following: 1. Immediate Action Taken A. DON/Designee completed a resident Pain assessment on resident #8, and #9, verified that these 2 residents did not have a negative outcome due to license nurse failure to either initial the E-MAR after the medication administration, or failure to sign out for the medication on the Narcotic controlled count sheet. Resident # 10 was discharged from the facility on 7/22/2023. This was completed on 8/13/2023 at 7:45 pm. B. On 8/13/2023 DON/Designee began education with all licensed nurses On Clinical Practice Guidelines Medication and Documentation with emphasis on: Administer the medication according to the physician order. Document initials and/or signature for medications and treatments administered on the E- MAR immediately following administration. When a controlled medication is administered the licensed nurse obtains the medication from the locked area. The licensed nurse administering the medication immediately enters the following information on the accountability record when removing the dose from controlled storage; date and time of administration, amount administered, signature of the nurse administering the dose. (Also document controlled medication dose administrated on the E-MAR) Strike out initials for those medication or treatment that were not administered and document reason for the non -administration in the clinical record. When a dose of a controlled medication is removed from the container for administration but refused or not given, the medication must be destroyed with two nurse witness. Both nurses sign the accountability record on the line representing the dose. Document PRN medication and treatment administration on the E-MAR along with the reason immediately following administration. Document effectiveness of the intervention on the E-MAR as indicated Review each E-MAR after each medication administration is completed and prior to the end of the shift to validate documentation is completed and supports services provided according to physician orders. Document omission or held medication on the 24- Hour Report Complete a Medication Error Report for medication administration discrepancies Provide a summary of medication administration issues to on-coming charge nurse during shift-to-shift report This education will be completed on 8/14/2023 by 10:00am and no licensed nurse will be able to work until this education has been completed. The DON/Designee will be responsible to ensure this education is completed and all licensed nurses understands bullet points above related to providing accurate administration and documentation of medication. 2. Identification of Residents Affected or Likely to be Affected: A. On 8/13/2023 DON/Designee identified all resident who receive a controlled medication and completed an audit to ensure that if a resident received a controlled medication, it was signed out on the Narcotic controlled count sheet, and that it was initialed on the E-MAR as given and that both the match. B. For discrepancies identified from the audit; the DON/Designee will complete a Medication Error Report for each identified issue, with immediate notification to Physician and Hospice provider if applicable. This will be completed on 8/14/2023 by 10:00 am. 3.Actions to Prevent Occurrence/Recurrence: A. DON/Designee will use The QAPI Narcotic Monitoring form daily x 30 day to ensure that all Controlled substances are reconciled with the E-MAR: It is signed out for on the Controlled Narcotic Count sheet, that it is initialed on the E-MAR at the time of administration There is documenting for omission or held medication on the 24- Hour Report There is a completed Medication Error Report for medication administration discrepancies If a dose of a controlled medication is removed from the container for administration but refused or not given, the medication was destroyed with two nurse witness. Both nurses sign the accountability record on the line representing the dose. On 8/13/2023 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Pharmacy Services and reviewed plan to sustain compliance. Verification: Started on 08/15/2023 at 2:35 and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 08/11/2023 and 08/13/2023: Observation on 08/16/2023, LVN C was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, RN B was observed during med pass by survey team, no discrepancies were observed. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Medication Administration Guidelines conducted by DON. 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Preventing and detecting adverse consequences and medication errors conducted by DON. 23 LVN's and 7 RNs were in-serviced between 08/11/2023 and 08/13/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Notification Change of Condition conducted by DON 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Interviews on 08/15/2023 between 8:00 am and 5:00 pm, the survey team interviewed 28 licensed staff (23 LVN's and 5 RN's), all 28 licensed staff verbalized understanding of what they learned during in-services they received between 08/11/2023 and 08/13/2023. Interview on 08/15/2023 at 9:30 a.m., LVN D was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 9:45 a.m., RN B was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 10:00 a.m., RN F was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview via telephone on 08/15/2023 at 11:55 a.m., LVN M was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Interview on 08/15/2023 at 3:15 p.m., LVN C was able to verbalize understanding of the following in-services received: Medication Administration Guidelines, Preventing and detecting adverse consequences and medication errors, and Notification Change of Condition. Record review of facility audits of eMAR's and Narcotic sheets of all residents receiving controlled substance medications were provided to Survey Team. Discrepancies discovered during the audit were reported to resident, resident's PCP, HHSC, police and noted on their progress notes. Record review of progress notes dated 08/15/2023 at 5:28 for Resident #8 revealed: Nurse informed primary care physician regarding Morphine eMAR missed documentation error which occurred on 2/4/23, 4/15/23, 4/24/23, 4/30/23, 5/16/23, 6/7/23, 6/11/23, 6/12/23, 6/24/23, 7/29/23, 8/5/23, 8/6/23, 8/7/23, 8/8/23, 8/9/23, 8/10/23, 8/12/23, 8/13/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse also informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by ADON 1 Record review of progress notes dated 08/15/2023 at 5:41 p.m. for Resident #8 revealed: Nurse informed primary care physician regarding Lorazepam eMAR missed documentation error which occurred on 4/27/23, 5/2/23, 05/03/23, 6/11/23, 6/12/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/I reach. Created by ADON 1 Record review of progress notes dated 08/15/2023 at 5:14 for Resident #9 revealed: Nurse informed primary care physician regarding Morphine eMAR missed documentation error which occurred on 6/10/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse also informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by ADON 1 Record review of progress notes dated 08/15/2023 at 5:46 for Resident #2 revealed: Nurse informed doctor regarding Ativan eMAR missed documentation error which occurred on 10/27/2022, 01/17/2023, 06/06/2023. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/I reach. Created by DON. Record review of progress notes dated 08/15/2023 at 05:46 for Resident #3 revealed: Nurse informed doctor regarding Tramadol eMAR documentation error which occurred on 05/18/23, 05/19/2023, 05/20/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON. Record review of progress notes dated 08/15/2023 at 05:22 for Resident #5 revealed: Nurse informed doctor regarding Tylenol # 3 eMAR missed documentation error which occurred on 04/19/23, 04/15/23, 04/16/23, 04/17/23, 05/2/23, 05/2/23, 05/4/23,06/05/23. Resident sustained no negative outcome related to error. MD gave no new orders r/t medication error. All due care rendered. No distress noted. Call light w/in reach. Record review of progress notes dated 08/15/2023 at 05:20 for Resident #6 revealed: Nurse informed doctor regarding Lyrica eMAR missed documentation error which occurred on 08/13/23 which time on narcotic sheet and eMAR did not completely match. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed resident of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON Record review of progress notes dated 08/15/23 at 5:24 for Resident #11 revealed: Nurse informed doctor regarding Tramadol medication error, RX ordered was completed but Resident continues to receive Tramadol without MD ordered on the following dates: 12/24/22, 12/25/22, 12/26/22, 12/27/22, 12/28/22, 12/29/22, 12/30/22, 12/31/22, 01/01/23, 01/02/23, 01/03/23, 01/04/23, 01/05/23, 01/06/23, 01/07/23, 01/08/23, 01/09/23, 01/10/23, 01/11/23, 01/12/23, 01/13/,23, 01/14/23, 01/15/23, 01/16/23, 01/17/23, 01/21/23, 01/23/23, 01/25/23, 01/26/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON. Record review of progress notes dated 08/15/2023 at 5:35 for Resident # 13 revealed: Nurse informed doctor regarding Tramadol eMAR missed documentation error which occurred on 07/17/23, 07/23/23, 08/07/23. Resident sustained no negative outcome related to error. MD gave no new order r/t medication error. Nurse informed RP of same. All due care rendered. No distress noted. Call light w/in reach. Created by DON Interview on 08/17/2023 at 10:56 a.m., DON said facility does have a policy in place regarding medication administration. DON was asked how often she would conduct audits to make sure the Controlled Substance Record of Administration and eMAR coincided with each other, her response was daily. She said she would conduct random daily audits whenever she passed by a medication cart, whenever she would see a nurse administering medication or during care plan meetings. She said she would go over the eMAR and the Controlled Substance Record of Administration to make sure all doses were documented. DON said eMAR system was implemented one year ago and all staff were trained on how to use it. Surveyor asked DON if she conducted daily random audits of the eMAR and the Controlled Substance Record of Administration how could she have missed so many entries for Resident #8 and Resident #9, her response was she would have to check with the nurses to see what happened. Administrator was also present during the interview but did not participate in the interview. DON said she would have to get with her Regional Nurse to see if a new policy needed to be drafted related to documentation of medication. Interview on 08/17/2023 at 11:45 a.m., DON said regarding drug diversion/missed documentation, I cannot personally answer but make sure we are complying. She said she does random (daily) audits on eMAR and Narc sheets to make sure they coincide. If there is an issue with the nurses not documenting on eMAR then that is on them because they have been trained 100 % by the facility and are board certified by the state of Texas. She said she cannot answer for those nurses that are not following policy. DON said her safety net is she conducts daily random audits and before 08/17/2023 she had not found any discrepancies during those daily random audits. DON said it was not until the Immediate Jeopardy was identified when she and ADON conducted 100% audits on all resident's eMAR, and Controlled Substance Record of Administration and discrepancies were identified. DON said facility has nurses that are not complying with their policy of documenting on eMAR, and it has been reported to the state as non-compliance. DON said police has also been notified. Administrator was present but did not participate in the interview. The DON said she had trained all licensed staff in the above trainings. She said she will be conducting daily reviews of all new medication orders during the morning meetings to verify all orders were entered correctly for 30 days. She/designee will review the 24-hour report daily for 30 days to verify that any resident with a change of condition has physician and family notification. The DON/designee will do random skill validation review with licensed nurses to verify medication administration competency and knowledge on what steps to take if a significant error occurs. The DON said she or designee will be responsible to ensure all licensed nurses were proficient in Medication Administration. Interview on 08/17/2023 at 12:40 p.m., Administrator said she has reported all discrepancies found in the above audits to the state and police. She said she will make sure DON/designee follow up on the conditions listed above for the next 30 days. Administrator said DON/designee will use the QAPI Narcotic form for 30 days to ensure all controlled substance are reconciled with the eMAR. The Immediate Jeopardy was removed on 08/17/2023 at 2:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents were free of significant medication errors for 1 (Resident #7) of 3 residents reviewed for medication errors in that: The facility did not follow physician's orders for Resident #7 when Resident #7 was administered 1 ml of Morphine Sulfate (concentrate) Oral Solution 100 MG/5ML (Morphine Sulfate) instead physician's order of 0.1ml morphine sulfate. An Immediate Jeopardy was identified on 08/11/2023. The Immediate Jeopardy template was provided to the facility on [DATE] at 7:23 PM. While the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m., the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on residents free of significant medication error. The failure could place residents at risk for complications and possible death from receiving the wrong or excessive dosage of medication. The findings included: Record review of Resident #7's admission Record dated 12/12/2022 indicated Resident #7 was an [AGE] year-old female and was admitted to facility on 09/28/2022 with the following diagnoses: of encephalopathy (a broad term for any brain disease that alters brain function or structure), COVID-19, lobar pneumonia (acute exudative inflammation of the entire lobe), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), gastro-esophageal reflux disease without esophagitis (a type of Gerd that does not involve inflammation of the esophagus), spinal stenosis, cervical region (narrowing of the spinal canal), dependence on supplemental oxygen, depression, acute respiratory failure with hypercapnia, type 2 diabetes mellitus without complications, hyperlipidemia (elevated levels of lipids like cholesterol and triglycerides in the blood), chronic pain syndrome, hypertension, chronic ischemic heart disease ( heart problems caused by narrowed heart arteries), peripheral vascular disease, constipation, secondary kyphosis (fracture in one or more vertebral bodies) spondylosis (age related wear and tear of the spinal disks), adult failure to thrive, and history of falls. Record review of Resident #7's MDS assessment, dated 12/15/2022 indicated: -BIMS score was 15 (cognitively status independent, decisions consistent/reasonable) -coded as being under hospice -required limited assistance with one person assist with bed mobility, transfer, walk-in corridor, walk-in-room, and toilet use -required supervised with one person assist for locomotion on unit, locomotion off unit, dressing and personal hygiene -was independent with setup help only for feeding -history of falls prior to admission/entry or re-entry Record review of Resident #7's comprehensive care plan dated 09/29/2022 revealed: Resident #7 was under hospice Focus: Resident #7 has a terminal illness and is receiving hospice or palliative care. During the end-of-life process weight loss, skin breakdown, dehydration, fecal impaction, and the gradual o or rapid loss of the ability to move may be unavoidable. Date initiated: 01/08/2023 Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of interventions through the next review. Date initiated: 01/08/2023 Interventions: Coordinate with hospice to ensure the resident's spiritual, emotional, intellectual, physical, and social needs are met. Date initiated 01/08/2023; Assist with ADL's and provide comfort measures as needed. Date initiated 01/08/2023; Monitor for abnormal weight loss, poor appetite, and skin breakdown. Report abnormals to the physician as noted. Date initiated 01/08/2023; Monitor for signs and symptoms of increased pain, discomfort-give medications and treatments as ordered and monitor for relief. Date initiated 01/08/2023. Record review of Resident #7's comprehensive plan dated 09/29/2022 revealed Morphine Sulphate (concentrate) Oral Solution 100 mg/5 ml (morphine sulfate) was not care planned. Record review of Resident #7's eMAR for January 2023 revealed: Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine Sulphate) Give 0.1 ml by mouth every 1 hours as needed for severe pain 7-10. Start date-01/09/2023 16:01 (04:01 p.m.) and discontinue date-01/11/2023 08:22. Further review of eMAR indicated Resident #7 did not receive Morphine Sulfate (concentrate) Oral Solution 100 mg/5ML (morphine sulfate) from January 09, 2023, through January 11, 2023. Physician's order was under orders on PCC. Record review of Resident #7's progress note dated 01/09/2023 at 16:04 (04:04 p.m.) revealed Note This order is outside of the recommended dose or frequency. Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain. Record review of Resident #7's progress note dated 01/10/2023 at 14:00 (04:00 p.m.) revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Record review of Resident #7's progress note date 01/10/2023 at 18:47 (06:47 p.m.) revealed eMAR Medication Administration Note: Duplicate Order - Note Text: Morphine Sulfate (Concentrate) Oral Solution 100 MG/5ML Give 0.1 ml by mouth every 1 hours as needed for Severe Pain 7-10 Pain Both progress notes dated 01/10/2023 at 14:00 (02:00 p.m.) and 18:47 (06:47 p.m.) had been stuck off. Record review of the hospital records dated 01/10/2023 at 18:23 (06:47 p.m.) revealed the following: Patient is an 87 y/o (year old) F (female) with PMH (past medical history) of DM (diabetes mellitus), CVD (cardiovascular disease) with no residual effect per son who presents as trauma admission s/p (status post) unwitnessed GLF (ground level fall) at 17:00 on 01/10/2023. Per family member, patient lives in a nursing facility and had a fall from her wheelchair as she was trying to get up. No LOC (loss of consciousness). Patient at baseline is non ambulatory; uses a wheelchair. On presentation, patient difficult to awaken, sternal rub elicits limited response. History limited due to patient's status; patient's family member present at bedside is also unclear of history. Physical Examination: General: minimally responsive; open eyes minimally after sternal rub. Eye: unable to examine HENT: V shaped laceration on the left side of forehead Respiratory: Lungs are clear to auscultation, respirations are non-labored Cardiovascular: Normal rate, regular rhythm, good pulse equal in all extremities Gastrointestinal: soft, non-tender, non-distended Musculoskeletal: unable to examine Integumentary: decubitus ulcer in sacral area and heal, present on admission Neurologic: minimally responsive to sternal rub Cognition and Speech: unable to examine Psychiatric: unable to examine. Impression and Plan Patient non arousable initially on exam. Head CT on arrival shows 0.4 subdural hematoma, repeat CT head recommended in the AM. Hospital Cause: Heat CT (cat scan) on arrival shows 0.4 mm subdural hematoma. Dr. consulted recommended repeat CT (cat scan) head the following morning which was stable with 4 mm subdural hematoma. No intervention per neurosurgery. Patient is complaining of neck pain with history of cervical stenosis, previous workup negative for acute cardiac pathology. Patient's family requested application to new SNF (skilled nursing facility), during her stay patient had no acute events. Patient is ready for discharge. Operative Report: Consent: signed by patient Location: forehead Preparation and technique: 3 sutures placed Interview on 08/10/2023 at 5:55 p.m. via telephone with LVN A revealed on 01/10/2023 at about 4:00 p.m. RN A came to the nurse's station where she was and advised her Resident #7 was requesting pain medication due to having neck pain. LVN A said she told RN A Resident #7 had recently been prescribed Morphine for pain. LVN A said she and RN A walked over to Resident #7's room because she wanted to make sure Resident #7 was alert and I just wanted to observe her to make sure she was in pain. LVN A said she had been in Resident #7's room a short time before and she did not complain of any pain. Upon entering Resident #7's room, Resident #7 was observed sitting in her wheelchair next to her bed. LVN A said Resident #7 did complain of neck pain and requested pain medication. At that time LVN A said she and RN A went outside to the hall and unlocked the med cart and pulled the Morphine box out and compared the label on the box with the order which indicated to give 0.1 ml as needed for pain every 1 hour. LVN A said after she and RN A verified the name, dosage, and route she went back to Resident #7's room to transfer her to bed while RN A stayed in the hall preparing the medication. LVN A said she transferred Resident #7 back to bed and advised her not to get up and if she needed anything to make sure to press the call light. Soon after that RN A came into Resident #7's room and administered Morphine. LVN A said RN A held up the syringe, showed it to her, and asked if it was ok to administer the Morphine, LVN A said, I didn't physically look at the syringe, but I said yes, and RN A administered the Morphine orally. LVN A said we both left back to the nurse's station and immediately RN A said she thought she had given Resident #7 the wrong dose of Morphine. At that point, LVN A replied, what do you mean RN A repeated I gave Resident #7 the wrong dose. LVN A said she immediately walked over to the med cart unlocked it and pulled the Morphine box out of the narc box to check the syringe. LVN A said after Morphine was given to a resident, the syringe was placed in a red plastic bag and placed back in the manufacture's box along with the Morphine. LVN A said when she checked the manufacture's box the syringe was not there. LVN A asked RN A where she had left the syringe and her response was I think I left it in Resident #7's room. LVN A said she went to Resident #7's room and found the syringe in a plastic bag on top of the dresser. At that point, RN A picked up the syringe and pointed to the 1.0 ml and told LVN A that's how much I gave her. LNV A said the facility has no protocol on how to manage medication errors, she said what she did after learning of the medication error what she learned in nursing school. LVN A said she immediately went to check on Resident #7 and found her to be alert, not in respiratory distress and still lying-in bed. LVN A said, I don't remember if RN A or I notified hospice nurse, DON, and family member but they were notified immediately of the medication error. LVN A said I went to check on Resident #7 a couple more times, she checked her breathing and was not in distress and was alert. LVN A said she does not remember the exact times she checked on Resident #7's saying, it's been a while. LVN A said between 5:30 p.m. and 5:45 p.m., a CNA was walking by Resident #7's room and noticed her laying on her left side on the floor. CNA called for help and LVN A ran to assist her. LVN A said Resident #7 was right by the door laying on her left side, bleeding from her forehead and had a bump on top of her scalp. LVN A said Resident #7 told her she managed to get out of bed, sit herself on her wheelchair when she tried reaching for something and fell. LVN A said she asked Resident #7 why she had gotten out of bed, and she replied, you know I'm stubborn. LVN A said she called Resident #7's doctor to inform of fall and was given instruction to send Resident #7 to the hospital to be evaluated. LVN A was asked if she notified Resident #7's doctor of the morphine dose error and she said yes adding I also notified the hospital when I called to let them know we were sending Resident #7 to the ER due to the fall. LVN A said Resident #7 was sent to the hospital due to the fall and not to the Morphine medication error. LVN A said Resident #7 had a history of falling and had received stiches on her head before due to the falls she had sustained since being admitted . LVN A said she made an incident report related to the medication error and the fall Resident #7 sustained on 01/10/2023. Surveyor asked LVN A how a medication error of Morphine negatively affect Resident #7 she replied to the most serious side effect could be respiratory distress. LVN A said the next day (01/11/2023) the DON and Administrator provided both she and RN A an in-service training on medication errors, were counseled individually and suspended for 3 days pending an investigation. Surveyor asked LVN A if RN A had given an explanation as to why she gave the wrong dose and she said RN A told her that in her previous job it was customary to give 1.0 of morphine so she figured it was the same at this facility. Interview via telephone on 08/11/2023 at 9:40 a.m., the PCP said he was not informed of Resident #7's morphine medication error. He said he wanted to make sure we understood this was the first time he was informed. The PCP said if he had been informed of the morphine medication error that would have unleashed a whole new protocol. Surveyor asked what he would have instructed the nurse to do, he replied, there would have been two possible responses. If resident was not experiencing respiratory distress, pulse was within range, she was cognitively aware, and heart rate was not abnormal, I would have instructed the nurse to observe the resident continuously (he did not say how long because everyone is different), resident did not need to be sent to the hospital because at that point because resident was stable. If the resident were experiencing respiratory distress, pulse was not within range, was not cognitively aware, and heart rate was abnormal, he would have instructed the nurse to administer Narcan and sent to hospital immediately. The PCP said Resident #7 received 10 times her prescribed order of morphine. The PCP said 1.0 is the max dose of morphine and not deadly for a hospice resident because eventually they will require a higher dose. The PCP said Resident #7 still needed to be monitored for any adverse effect. Interview via telephone on 08/11/2023 at 10:30 a.m., The Hospice DON said Resident #7 was placed on hospice due to respiratory failure. The Hospice DON said facility called hospice at 09:32 p.m. on 01/10/2023 to inform them Resident#7 suffered a fall and sent to the hospital due to sustaining a hematoma to her forehead. The Hospice DON said on 01/11/2023 at 11:15 a.m. Facility's DON called them and advised of the morphine medication error. The Hospice DON said facility's DON said the syringes that came in the manufacture's box of the morphine medication did not have numbers only lines and that could have caused the RN A to administer the wrong dosage of morphine to Resident #7. The Hospice DON said the medication/syringe was delivered by the pharmacy and it was considered a multi-use syringe. The Hospice DON said as a correction plan the hospice company delivered 10 to 15 syringes with numbers to avoid another medication error. The Hospice DON was asked if facility had called immediately, she would have sent their hospice RN to go to facility and assess Resident #7 at facility. The Hospice DON if the facility had notified them as soon as the medication error said she would have also instructed hospice RN to check her level of consciousness more frequent, her vitals for hypertension and fall precautions for at least 2 hours after medication error. The Hospice DON said Narcan would have been ordered depending how Resident #7 looked. Interview via telephone on 08/11/2023 at 11:00 a.m. The Hospice DON called back to say she had spoken to previous acting hospice DON (at time of incident) who had clarified the first-time facility's DON had reported morphine medication error was on 01/11/2023. The Hospice DON also verified they had notified Resident #7's primary physician of her fall on 01/10/2023 at 9:30 p.m. Interview on 08/11/2023 at 11:15 a.m., LVN A said she had struck out Morphine entry on progress notes at 18:47 on PCC because she was not the one who had administered the morphine to Resident #7. Interview via telephone on 08/11/2023 at 12:50 p.m., RN A said on January 10, 2023, at approximately 4:00 p.m. while working under the supervision of LVN A (as it was her first day on the floor since being hired) She walked into Resident #7's room to check on her. RN A said Resident #7 complained of neck pain and requested pain medication. She immediately went looking for LVN A and found her in the nurse's station. She informed LVN A Resident #7 was requesting pain medication due to neck pain. Staff F said she was told by LVNA Resident #7 was under hospice care and had a PRN (as needed) order of Morphine. RN A said she proceeded to the medication cart to prepare the syringe with the morphine solution. RN A said after she prepared the syringe with the morphine solution, she went looking for LVN A. RN A said she found LVN A in the medication storage room and appeared to be talking to someone on the phone because she had an ear pod in one ear. RN A said she signaled LVN A though the glass window to come out. RN A said LVN A opened the door without coming out and at that time they both checked the Morphine order with the label, name, dose, route, and I showed her the syringe with the morphine solution, and she nodded yes, she gave me a thumbs up. RN A said she then proceeded to Resident #7's room to administer the morphine. RN A said she first educated Resident #7 on the medication she was going to receive and transferred her back to her bed and administered the Morphine oral solution. RN A said she went to check on Resident #7 after 30 minutes or 1 hour (was not sure on the time) and Resident #7 was good being her normal self. RN A said, we did our thing throughout our shift and around 5 or 6 p.m. LVN A calls out for help because Resident #7 had fallen and had a wound on her forehead. RN A said she stayed with Resident #7 while LVN A went to call 911. LVN A said Resident was found between her bed and bathroom. RN A said she discovered the morphine medication error at about 6:30 p.m. when she was looking back at the eMAR and discovered I had given more than I should RN A said she immediately informed LVN A but does not remember what her response was. RN A said, I texted DON at 6:31 p.m. telling her LVN A and I wanted to meet with her tomorrow to review possible med error. RN A said she texted DON because it was after working hours for DON. As per RN A, DON responded back via text at 7:00 p.m. telling her Yes, please do so. RN A said Resident #7 had already been discharged to the hospital by the time she discovered the morphine medication error. RN A said sometime before the end of her shift LVN A told her We could have fixed it RN A reply to LVN A was there's no fixing, I gave what I gave. Surveyor asked RN A if she knew what RN A meant by that and she said, to put 0.1 ml in the narc sheet even though I had given 1.0 ml of morphine. RN A said the next morning, DON met with both and them together and individually. She said they also had a general training with all nurses to make sure all nurses were doing their job. RN A said she received training on how to read eMAR and was not sure on the topics of other trainings received after med error incident. She said she and LVN A were suspended pending the outcome of the investigation. Surveyor asked RN A how Resident #7 could have been negatively impacted by receiving 1.0 ml of morphine sulfate instead of the ordered 0.1 ml, she said her breathing distress and high blood pressure. Staff F said 1.0 ml of morphine sulfate is appropriate for hospice patients but there must have been a reason Resident # 7's doctor had prescribed 0.1 ml of morphine sulfate. RN A said she decided to voluntarily quit her job as a registered nurse at the facility because she was told by someone RN A had written a statement saying she had never shown her the syringe. RN A said she believed they would take LVN's statement over her since she had just been hired. RN A also said it was not a healthy environment and did not feel comfortable working at the facility. RN A said she took a picture of the syringe used to administer the morphine sulphate to Resident #7. Interview via telephone on 08/11/2023 at 11:20 a.m. The Medical Director said he was informed of Resident #7's medication error by the facility's nurse on duty (did not have nurse's name) on 01/11/2023 and was not sure of the time either. The Medical Director said he and the rest of the QAPI team discussed medication error on 02/23/2023. The Medical Director said during the meeting they checked narcotic orders for all residents. The Medical Director was asked how Morphine medication error could negatively impacted Resident #7 and his response was she could have suffered neurological sedation, respiratory depression or excessive sedation but added Resident #7 did not have any negative effects. The Medical Director said if Resident #7 had suffered any side effects he would have ordered Narcan and sent to the hospital immediately. The Medical Director emphasized he was available to the facility 24/7 and facility did not notify him immediately. Interview on 08/11/2023 at 3:00 p.m., The DON said she expects all her nurses to inform her immediately in case of a medication error. She said if she is not at facility (after working hours) she expects a call from them immediately. The DON said she would ask the nurse what medication was given, the dosage and the correct dosage and depending on what they would tell her, she would instruct them to either monitor or send to hospital. The DON said she immediately notifies resident's primary physician, family representative, medical director, and administrator of the medication error. The DON said after resident is cared for, she will complete the medication error report, start an investigation, re-educate staff and report to HHSC. The DON said the medication error was discovered after Resident #7 was discharged to the hospital due to sustaining an unwitnessed fall. The DON said Resident #7 had a history of falls and was non-compliant. The DON said she notified Resident # 7's primary doctor and hospice immediately of the fall but was not sure if she informed them of the medication error on the same day. The DON said the fall or medication error was not care planned because Resident #7 did not go back to facility after being discharged from hospital. Interview on 08/11/2023 at 3:30 p.m., The Administrator said facility's policy regarding medication error was for the nurses to let the DON know immediately after discovering a medication error was occurred. The Administrator said depending on how the resident was feeling, DON will instruct of appropriate action. The Administrator said it was the DON's responsibility to inform her of any medication errors immediately after being notified of one. The Administrator was asked how a morphine medication error could negatively affect Resident #7; her response was I don't know how to answer that question. Observation on 08/11/2023 at 1:41 p.m., RN A texted picture to surveyor and it showed a thin syringe with 4 lines (0.25 ml, 0.50 ml, 0.75 ml, and 1 ml). Record review of the facility policy titled Prevention of Medication Errors dated 05/30/2018 indicated: Anticipated Outcome Residents will be free of incidents related to medication Fundamental Information Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specification or accepted professional standard and principals. Significant medication error: means one which caused the resident discomfort or jeopardizes his or her health and safety. Review MAR to identify medication to be administered Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Administer medication as ordered with the appropriate amount of fluid or food. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR at the time of medication administration. If medication is a controlled substance, sign narcotic book and complete other standard of practice documentation Nurse /Medication Aide will be able to identify or have quick reference of action and common side effects of medication. Correct any medication discrepancies and report to director of nursing Staff education regarding risk of medication errors The Administrator was informed the Immediate Jeopardy was removed on 08/13/2023 at 6:54 p.m. The facility remained out of compliance at a severity level of 4 and a scope of J due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 1. Immediate Action Taken On 1/10/2023 resident # 7 was sent to the hospital and never returned to the facility. On 8/11/2023 DON/Designee completed an audit of all residents receiving Morphine in the center to verify that correct dose of Morphine was entered into the computer. This will be completed at 10:00 pm on 8/11/2023. On 8/11/2023 DON/Designee completed rounds on all residents to verify that a physician's notification was completed if a resident was identified with a change of condition. No residents were identified On 8/11/2023 DON/Designee started education with all licensed nurses on: o Policy on Medication Administration Guidelines that provide directions on the process of verifying labels for accuracy, verifying administration accuracy, verifying a focused assessment, administering the medication according to the physician's orders. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o Policy on Preventing/Detecting adverse consequences and Medications errors that provides directions to license nurses on immediate actions to take for a signification medication related error or adverse consequence: License nurse will notify the attending physician promptly of any significant error or adverse consequence License Nurse will Immplement (that is how it was written on POR) orders as directed by physician, and the resident is monitored closely for 24 to 72 hours or as directed. License Nurse will Communicate with other across shifts as indicated to alert staff of the need to monitor resident License Nurse will Complete an Incident report or Medication error form License Nurse to Report significant error to the DON DON will report significant error to Consultant Pharmacist This will be completed by 3:00 pm on 8/12/2023, and no licensed nurse will be allowed to work until they have received this education. The DON/Designee will be responsible for ensuring all license nurses understand and follow the guidelines for a significant error or adverse consequence. o Policy on Notification Change of Condition that provides directions on notifying family and physician when a change in a resident's conditions occurs. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. o A skills competency on Medication Administration will be completed for all license nurses, validating proficiency in Medication Administration to validate medication administration competency and action to take if a significant error occurs. The DON/Designee will be responsible to ensure all license nurses are proficient in Medication Administration. This will be completed by 10:00 pm on 8/11/2023, and no licensed nurse will be allowed to work until they have received this education. 2. Identification of Residents Affected or Likely to be Affected: On 8/11/2023 DON/Designee started an audit review of all residents with new orders for the past 7 days to verify that correct dose of medications was entered into the computer correctly and no significant error occurred. This will be completed by 10:00 am on 8/12/203. 3. Actions to Prevent Occurrence/Recurrence: The DON/Designee daily will review all new medication orders during the morning meeting to verify all orders were entered correctly x 30 days. The DON/Designee daily will review the 24-hour report daily x 30 days to verify that any resident with a change of condition has physician and family notification. The DON/Designee will do random skills validation reviews with licensed nurses to verify medication administration competency and knowledge on what steps to take if a significant error occurs. The DON/Designee will be responsible to ensure all licenses nurses are proficient in Medication administration. On 8/11/2023 at 8:15pm the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy's the facility received related to residents free from significant medication error and Notification in change of condition and reviewed plan to sustain compliance. Verification: Started on 08/15/2023 at 2:35 and included: The following observations, record reviews and interviews were conducted by the survey team to ensure licensed staff's understanding of in-service trainings received between 08/11/2023 and 08/13/2023: Observation on 08/16/2023, LVN C was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, LVN D was observed during med pass by survey team, no discrepancies were observed. Observation on 08/16/2023, RN B was observed during med pass by survey team, no discrepancies were observed. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Medication Administration Guidelines conducted by DON. 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Preventing and detecting adverse consequences and medication errors conducted by DON. 23 LVN's and 7 RNs were in-serviced between 08/11/2023 and 08/13/2023. Record review of the licensed nurses In-Service Program Attendance Record for the following topic Notification Change of Condition conducted by DON 23 LVN's and 7 RN's were in-serviced between 08/11/2023 and 08/14/2023. Interviews on 08/15/2023 between 8:00 am and 5:00 pm, the survey team interviewed 28 licensed staff (23 LVN's and 5 RN's), all 28 licensed staff