**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors, in that: The facility did not administer Resident #1's recommended doses for dexlansoprazole [a medication used to reduce stomach acidity and prevent stomach ulcers] and sucralfate [a medication used to coat the lining of the stomach and intestinal ulcers by forming a barrier over the ulcers and protecting the ulcer from further injury] from 11/11/2023 to 11/27/2023, resulting in the resident being sent out to the hospital on [DATE]. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 12/1/23 at 5:37 p.m. While the IJ was removed on 12/2/23 at 9:48 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This deficient practice could affect residents and place them at risk for not receiving a therapeutic effect. The findings were: Record review of Resident #1's face sheet, dated 12/1/23, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, lamellar ichthyosis [a rare skin condition that causes dark, plate-like scales on the body], gastrointestinal hemorrhage, unspecified, Barrett's esophagus with dysplasia [a condition where damage by acid reflux causes the esophagus to become red and thick and it also causes the cells in the esophagus to become abnormal], unspecified, and congenital hiatus hernia [also known as a hiatal hernia, when the upper part of the stomach bulges through the large muscle separating the abdomen from the chest]. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS of 11, signifying moderate cognitive impairment. Record review of all of Resident #1's active and discontinued physician orders, obtained 12/1/23, revealed the following: - Dexlansoprazole Oral Capsule Delayed Release 30 MG (Dexlansoprazole) Give 1 capsule by mouth in the morning for gerd [also known as GERD, Gastro-Esophageal Reflux Disease, which is acid reflux.] This was ordered on 9/29/23 and there were no other updates or changes to this medication's dosage or schedule since it was ordered on 9/29/23. - Sucralfate 1 GM Tablet Give 1 tablet by mouth two times a day for ESOPHAGITIS [inflammation of the esophagus] GIVE 1 TABLET BY MOUTH TWO TIMES A DAY FOR ESOPHAGITIS***MAY CRUSH AND DISSOLVE IN 10ML OF WATER TO FORM A SLURRY*** This medication was ordered on 9/30/23. Record review of Resident #1's nursing progress notes revealed the following: - Nursing Progress Note, dated 11/8/23 and written by LVN D: pt had coffee ground emesis, no signs of distress noted New order to send Pt to [local hospital emergency room] for eval and treat. There was no progress note regarding any medication reconciliation when Resident #1 returned from the hospital on [DATE]. Record review of Resident #1's electronic health records revealed the facility had a copy of Resident #1's hospital records from his admission to the hospital from [DATE] to 11/11/23. Record review of Resident #1's hospital records, dated 11/9/23, revealed the following: PRINCIPAL OBSERVATION ADMIT DIAGNOSIS: Coffee ground emesis . ALL PRINCIPAL OBSERVATION DISCHARGE DIAGNOSES: erosive esophagitis [damage to the lining of the esophagus, typically caused by acid reflux]. PERTINENT admission HISTORY & PHYSICAL EXAM . [Resident #1] is a [AGE] year old MALE patient with [past medical history] of dementia, upper GI bleeding and recurrent episodes of coffee-ground emesis due to LA-D erosive esophagitis [LA is a type of grading system for esophagitis; a grade of a D indicates damage to 75%or more of the esophagus' perimeter], hiatal hernia . sent in . for episode of coffee-ground emesis today. Active Outpatient Medications . Dexlansoprazole 60 mg EC Cap take one capsule by mouth twice a day for stomach . Sucralfate Oral susp 1gm/10mL take 10 mL by mouth four times a day before meals for stomach ulcer. Please make sure that patient takes sucralfate 30 minutes before meals. Record review of Resident #1's electronic Admission/readmission Evaluation, dated 11/12/23 and signed by LVN A, revealed no documentation of medication reconciliation or review of Resident #1's discharge documentation immediately following his return to the facility on [DATE]. Record review of Resident #1's November 2023 MAR and TAR, dated 12/1/23, revealed Resident #1 received the following medications: - 30 mg of Dexlansoprazole once every morning throughout the month of November 2023 except when he refused the medication on 11/1/23, when he went to the hospital from [DATE] to 11/11/23, and when he went to the hospital again from the late morning of 11/27/23 through 11/30/23. - 1 GM tablet of Sucralfate twice a day throughout the month of November 2013 except when he went to the hospital from [DATE] to the morning of 11/11/23, when he refused the medication on 11/17/23, when he refused the medication on 11/27/23, and when he went to the hospital from late morning of 11/27/23 through 11/30/23. Record review of Resident #1's nursing progress notes revealed the following: - Nursing Progress Note, dated 11/27/23 and written by LVN E: it was noted that the patient had emesis x2 [two times] during the morning 6 and 7 am, a call was placed to the on call for [Physician B] and gave order to send out to the emergency room. There were no progress notes between 11/11/23 to 11/27/23 indicating any changes to Resident #1's dexlansoprazole and sucralfate. Record review of Resident #1's hospital Gastroenterology Consultation note, dated 11/27/23, revealed the following: This is a [AGE] year-old male with [past medical history] of advanced dementia . erosive esophagitis, hiatal hernia . admitted from . nursing home for coffee ground emesis. [Family member] mentions . [Resident #1] likely is not getting the 'right doses of meds.' .On review of the patient's med rec dated 11/27, he appears to be on Dexlansoprazole 30 mg qAM; however per his . med rec as well as our previous notes, he has been recommended Dexlansoprazole 60 mg PO BID (and would need BID dosing in the setting of high-grade esophagitis.) . Active Problems . 2. Acute upper gastrointestinal hemorrhage, 3. Gastro-esophageal reflux disease [acid reflux] with esophagitis . Likely etiology [cause] of bleed is still likely to be high grade esophagitis demonstrated on repeat EGD [a procedure that visualizes the upper part of the digestive tract to the beginning of the small intestine], especially in the setting of underdosing of his PPI [referring to Dexlansoprazole.] Record review of Resident #1's hospital History and Physical, dated 11/27/23, revealed the following: per records for the facility, patient has been receiving dexlansoprazole 30 mg daily instead of prescribed dose of 60 mg bid, possibly contributing to recurrence of coffee ground emesis and melena [blood in the stool.] During an interview on 12/1/23 at 12:40 p.m., Resident #1's family member stated Resident #1 went to the hospital on [DATE] because Resident #1 had bloody emesis. Resident #1's family member stated Resident #1 went to the hospital on [DATE] because of the same reason, the bloody emesis. Resident #1's family member stated the cause of the bloody emesis was because of Resident #1's compromised esophagus and the ulcer. Resident #1's family member stated she was not sure if the ulcer was a new or chronic condition. Resident #1's family member stated, I do know that this time in the hospital, in the ER, one of the doctors came in and he was aghast and said, 'they're not giving him the right doses on his medication,' and he lamented that they were only giving a fourth of the dose that they prescribed.That particular medication was that it helps soothe the lining of the esophagus because he has a compromised esophagus and eating sometimes irritates it and he throws up blood emesis. Resident #1's family member stated she did not want Resident #1 to return to the facility. During an interview on 12/1/23 at 1:34 p.m., LVN A stated when a resident was admitted an assessment was done and the medication records were reviewed. LVN A stated, You go over [the records] and see if anything's changed or anything's different. LVN A stated he would review the discharge documentation and the final medication list and if there were any changes he would call the physician and let the physician know a medication had changed. LVN A stated usually a second per son also reviewed the documentation. LVN A stated he recalled Resident #1 went to the hospital on [DATE] due to coffee ground emesis, but did not recall if he was the nurse who readmitted Resident #1 back to the facility on [DATE]. LVN A stated he was not working on 11/11/23. LVN A stated he did not know why his name was on Resident #1's electronic readmission form dated 11/12/23. LVN A stated, Maybe I was trying to backdate something. I couldn't remember. During an interview on 12/1/23 at 2:02 p.m., the interim DON stated upon admission an assessment of the resident, a review of the orders, and a medication reconciliation was done. The interim DON stated the discharge summary or clinical packet from the hospital should be reviewed. The interim DON stated, Most of the time [the hospital] fax[ed] over a clinical packet with an order from the doctor that says 'continue orders as per discharge summary' or some randomness that we go through to make sure the orders are correct. Then we can clarify with the physician. The interim DON stated the ADONs reviewed the new admission either the same day or the next business day and if the resident returned to the facility after business hours or during the weekend then the ADONs reviewed the new admission the next business day. The interim DON stated the nurse who admitted Resident #1 back to the facility on [DATE] was LVN A. The interim DON stated, a dose was changed on [Resident #1's] dexlansoprazole that was not-the reconciliation did not happen and his dose continued at his previous dose. The interim DON stated she did not know exactly when the dexlansoprazole dosage was changed. When asked what could have caused Resident #1's medication reconciliation to be missed on 11/11/23, the interim DON stated, the fact that it was a Saturday night, towards the end of the shift, and the process wasn't followed Monday morning. That's my deduction was that they weren't following the in-place policy and procedure. When asked if the facility had a quality assurance process that ensured medication reconciliation was done upon readmission, the interim DON stated, the ADONs reviewed all orders. When asked what sort of negative effect could occur to the resident if medication reconciliation wasn't done after readmission, the interim DON stated, The resident's condition could worsen. When asked what sort of negative affect could occur if a resident was receiving a medication at a lower dose, the interim DON stated, They [the resident] could not be treated effectively. In a follow-up interview on 12/1/23 at 3:15 p.m., the interim DON stated she was not aware there was a change in Resident #1's sucralfate dose. The interim DON stated following Resident #1's admission to the hospital on [DATE], the facility had not completed an in-service for ensuring medication reconciliation. During an interview on 12/1/23 at 3:21 p.m., the interim Administrator stated he knew Resident #1's recent admissions to the hospital were related to the gastrointestinal issues and emesis. The interim Administrator stated he was not aware of any medication issues when Resident #1 returned to the facility on [DATE]. The interim Administrator stated, clearly our process didn't work for reviewing the readmitted patients for [Resident #1] because the medication-it was for stomach acid-it was 30 mg when he left, when he came back it had been changed to 60 mg, I think it was. In the morning meeting, in clinical, we should have reviewed that. And we should have caught it at that point. That was the safety net because the nurse, when they readmitted the patient, they failed to put the new orders in. I think the administrative nurses were working the floor and it got overlooked. The interim Administrator stated he was not aware Resident #1's sucralfate dose was also increased. When asked if the facility had completed education on medication reconciliation, the interim Administrator stated he personally didn't conduct any education but he stated the clinical or regional nurse could have conducted the education. During an interview on 12/1/23 at 2:56 p.m., Physician B stated Resident #1 was one of the patients seen by himself as well as the group of physicians he was a part of. Physician B stated he heard Resident #1 was sent out to the hospital. Physician B stated he was not aware of any issues with Resident #1's medications and was not aware of any changes to Resident #1's dexlansoprazole or sucralfate doses. Physician B stated a proton pump inhibitor (like dexlansoprazole) would be necessary if a resident had an ulcer. During an interview on 12/2/23 at 2:10 p.m., ADON F stated the day Resident #1 returned to the hospital on [DATE] was a weekend. ADON F stated the admitting nurse must have received the packet and Resident #1 was on 30 mg of dexlansoprazole before. ADON F stated when Resident #1 came back from the hospital the dose was changed to 60 mg. ADON F stated she believed the change was omitted by the nurse, meaning the 60 mg change was not done and Resident #1 continued on the 30 mg dose. During an interview on 12/2/23 at 3:54 p.m., LVN E stated she sent Resident #1 to the hospital because he had black emesis. LVN E stated she was not aware of any concerns about Resident #1's gastrointestinal medication. LVN E stated she did not notice Resident #1's dexlansoprazole and sucralfate medication doses had increased. Record review of the facility's staff roster, dated 12/2/23, revealed the facility had 33 nurses. Record review of an educational in-service, dated 11/28/23, revealed 12 staff members were educated on the medication administration policy and on medication reconciliation. Of the 12 staff members, 8 were nurses. Record review of a facility policy titled, Medication - Administration, not dated, revealed the following: Medications may be administered one hour before or after the scheduled medication administration time. Record review of a facility policy titled, Drug Regimen Review, dated 6/2020, revealed the following: Upon admission, medications will be reviewed with the attending physician to identify clinically significant risks and/or actual potential adverse consequences which may result from or be associated with medications. The Administrator was notified of an IJ on 12/1/23 at 5:30 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 12/2/23 at 9:34 a.m. and included the following: Identify residents who could be affected. Residents who are admissions or readmissions have the potential to be affected. Identify responsible staff/ what action taken. 1. Director of Nurses and Assistant Director of Nursing (ADON) re-educated by the Regional Clinical Nurse on the facility policy for reconciliation of medications on admission/readmission on [DATE]. 2. All RN and LVN's educated on procedure of reconciliation of medications on all admission/readmission on [DATE] by Regional Clinical Nurse/DON. 3. ADON's were re-educated on medication reconciliation of all admission/readmissions to ensure reconciliation. Education was completed on 12/1/2023. 4. An audit on all admissions/readmissions in past 30 days to ensure accuracy of medication reconciliation was started on 12/1/2023 and will be completed 12/2/23. 5. All new hires will be educated on this process by DON/Designee prior to starting work. This will be ongoing. In-Service conducted. 1. Director of Nurses and ADON's re-educated by the Regional Clinical Nurse on the facility policy for reconciliation of medications on admission/readmission on [DATE]. 2. All RN and LVN re-educated on procedure of reconciliation of medications on all admission/readmission on [DATE] by Regional clinical Nurse/ DON. 3. ADON's were re-educated on medication reconciliation of all admission/readmissions to ensure reconciliation. Education was completed on 12/1/2023. Implementation of Changes Director of Nurses and Regional Nurse Consultant were re-educated on the facility policy for reconciliation of medications on admission/readmission on [DATE] by Director of Clinical Education. All RN and LVN re-educated on procedure of reconciliation of medications on all admission/readmission on [DATE] by Regional clinical Nurse/ DON. ADON's were re-educated on review of all new admission/readmissions, medications to be checked to ensure reconciliation is completed on 12/1/2023. All new hires will be educated on this process by DON/Designee prior to starting work. This will be ongoing. An audit on all admissions/readmissions in past 30 days to ensure accuracy of medication reconciliation was started on 12/1/2023 and will be completed on 12/2/23. DON/ADON's will review all admission/readmission orders to ensure accuracy of medication reconciliation within 24 hours of admission/readmission. All re-education and audits were initiated 12/1/2023 by the Regional Nurse Consultant/DON. The changes were implemented effective on 12/1/2023 and re-education is ongoing. Staff will not be allowed to work until they have been fully re-educated. All new hires will be educated on medication reconciliation, prior to working the floor by DON/Designee. The DON/Designee will ensure competency through signing of in service and verbalization of understanding. DON/Designee will complete audit of all admissions/readmissions daily. Monitoring The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on 12/1/2023 and ongoing. -The Director of Nursing/Assistant Director of Nursing/Regional Nurse Consultant will monitor/review all new admission/readmission daily x4 weeks, then weekly thereafter to be ongoing and report any adverse findings to the QAPI committee. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/1/2023 and conducted an Ad HOC QAPI regarding ensuring orders on all new admissions/readmissions are reconciled accurately and in a timely manner. The Medical Director was notified about the immediate Jeopardy on 12/1/2023, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 12/1/2023. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of New Process. The New Process/ system was started on 12/1/2023. The surveyor verification of the Plan of Removal on 12/2/23 was as follows: During an interview on 12/2/23 at 2:10 p.m., ADON F stated she received education on the medication reconciliation policy. ADON F stated she received education to include the review of all new admission/readmissions to ensure medication reconciliation. ADON F was able to explain the process for medication reconciliation. During an interview on 12/2/23 at 2:20 p.m., the Director of Clinical Education stated she educated the DON, ADON, and the Regional Clinical Nurse on the facility policy for reconciliation of medications on admission/readmission on [DATE]. During an interview on 12/2/23 at 3:09 p.m., the interim DON stated she received education on the medication reconciliation policy. The interim DON stated she had informed all staff that they were not allowed to work until they received the new education on medication reconciliation. The interim DON stated she planned on being present at the change of shift to ensure all staff members are educated prior to the start of the shift. The interim DON stated the audits would be conducted daily, including the weekends by herself and the ADONs. The interim DON stated an audit of residents who were admitted /readmitted within 30 days was completed by several administrative nurses. The interim DON stated the facility had a new addition to the new hire education to include education for the medication reconciliation. The interim DON stated the admission/readmission audits would be done daily and the resultswouldl be reported to the QAPI meeting. The interim DON stated she would provide oversight over the ADONs to ensure the completion of the admission/readmission audits. These audits will then be presented to the facility's morning meeting. During an interview on 12/2/23 at 2:24 p.m., the interim Administrator stated he was responsible for the implementation of the New Process. The interim Administrator stated the audits would be reviewed in the morning meeting and the nursing staff attending the morning meeting will be reviewing the resident's medical chart at the same time to ensure the medication reconciliation was completed. During an interview on 12/2/23 at 4:05 p.m., the interim Administrator stated an adhoc QAPI meeting was completed on 12/1/23 to discuss the findings of the immediacy and POR. During interviews conducted on 12/2/23 from 12:57 p.m. to 7:53 p.m., a total of 20 LVNs and RNs were interviewed. This included 4 administrative nurses, 3 7am - 3pm nurses, 4 3pm - 11pm nurses, 4 11pm - 7am nurses, and 5 double-shift nurses (7am - 3pm, 3pm - 11pm) were interviewed. All staff interviewed confirmed they received education on medication reconciliation for admissions and readmissions. All staff were able to verbalize understanding of the in-service and the medication reconciliation process. Record review of the facility's educational sign-in sheet, dated 12/2/23, revealed the facility had 33 RNs and LVNs employed. Of the 33 staff, 33 had been educated as of 12/2/23. Record review of educational sign-in sheet, dated 12/1/23, revealed the Regional Clinical Nurse and the DON were re-educated on the admission and Transfer policy and Medication Drug Regimen Review policy. ADON F was educated the admission and Transfer policy and Medication Drug Regimen Review policy on 12/2/23. Record review of educational in-services, dated 12/2/23, revealed the facility's ADONs have received the education on admission/readmission and medication reconciliation. Record review of an untitled facility report revealed 60 residents had been admitted within the last 30 days. Record review of an untitled document, dated 12/2/23, revealed the facility completed its audit to ensure medication reconciliation was completed for admissions and readmissions within the last 30 days. Record review of 3 residents who were recently admitted /readmitted within the last 30 days revealed all medications appeared to be current and ordered as prescribed. Record review of untitled document, not dated, revealed the facility had an audit form in place for readmissions and admissions including a column to ensure orders were reconciled by the nurse, completed by the DON, discrepancies were noted, and that the MD and nurse manager were notified. Record review of a facility document, titled [facility name] New Hire Nurse Education, not dated, revealed a new document had been created to accommodate the new education on medication reconciliation for new hires. Record review of QAPI form, dated 12/1/23, revealed a QAPI meeting was conducted regarding the IJ and the plan of removal. Record review of the facility's QAPI agenda, dated for 12/19/23, revealed the facility will discuss the results of their admission/readmission audits int eh QAPI Meeting. On 12/2/23 at 9:48 p.m., the interim Administrator and the interim DON were notified the IJ was removed. While the IJ was removed on 12/02/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy because the facility needed to monitor their corrective actions.