**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 22 sample residents, that the facility did not ensure each resident was free of significant medication errors. Specifically, a resident with a known allergy was administered a medication she was allergic to and required Narcan. This finding resulted in a harm level deficiency. In addition, another resident that required medication with food was not administered medication with food. Resident identifiers: 28 and 195. Findings include: HARM 1. Resident 195 was admitted to the facility on [DATE] with diagnoses which included after care following joint replacement surgery, morbid obesity, hypertension, hyperlipidemia, and encounter for prophylactic measures. On 8/16/21 at 12:00 PM, an interview was conducted with resident 195. Resident 195 stated that facility staff over medicated and dehydrated her. Resident 195 stated that she was given pain medication that she was allergic to and had to go to the emergency room (ER) at the local hospital. Resident 195's medical record was reviewed on 8/18/21. Resident 195's discharge order from a local hospital dated 8/14/21 revealed an allergy to Lidocaine, Latex and Lortab. The discharge medication orders revealed a new order for Oxycodone-acetaminophen 5mg (milligrams)-325 mg oral (Lortab). There was no documentation on how often to administer the medication. According to resident 195's electronic medical record at the facility resident 195 was allergic to Latex, Lidocaine and Lortab Elixir. Resident 195's August 2021 Medication Administrator Record (MAR) revealed Hydrocodone-acetaminophen 5mg-325 mg (Lortab) was administered on 8/15/21 at 10:12 AM. Resident 195 was administered Tizanidine on 8/14/21 at 10:52 PM, 8/15/21 at 10:01 AM, and 8/15/21 between 10:00 AM and 2:00 PM. According to Mayo Clinic, Hydrocodone and Acetaminophen, Oral route. https://www.mayoclinic.org/drugs-supplements/hydrocodone-and-acetaminophen-oral-route/description/drg-20074089. United States Brand Name was Lortab. The product was available in the following dosage form of Elixir. On 8/15/21 at 6:58 PM, a nurses note revealed that Tizanidine was administered and after patient became dizzy when ambulating.Patients blood pressure became hypotensive. CNA (Certified Nursing Assistant) reported low blood pressure during afternoon vital check. Nurse took manual blood pressure and it was 70/40. Nurse reported to ON call. Nurse received order to give 1 L (liter) NS (normal saline). Nurse started 1L NS. Patient was very lethargic and having a hard time staying awake and responding. After 650ML nurse retook patients vitals. BP was undetectable. Nurse was unable to get manual or automatic. Nurse let on call know status and received orders to call paramedics. EMS (Emergency Medical Services) was unable to get patients blood pressure. EMS took patient via stretcher. Nurse called and gave report to ER. An ER note dated 8/15/21 revealed that resident 195 was diagnosed with dehydration, polypharmacy, renal insufficiency, and hypotension. The physician ordered to .decrease your dose of Percocet for time being and HOLD your blood pressure medications until your blood pressure is consistently elevated about 140. On 8/16/21 at 1:06 AM a nursing note revealed, Resident returned from [local hospital] ED (emergency department) Physician noted 'Please decrease your dose of Percocet for the time being, and HOLD your blood pressure medications until you blood pressure is consistently elevated above 140'. In phone report, .RN (Registered Nurse) stated the physician's desire that we hold Percocet unless pain is uncontrolled by other medications. 1 Liter of fluids was also given while in the ED. On 8/18/21 at 12:33 PM, an interview was conducted with RN 3. RN 3 stated she was an agency nurse. RN 3 stated that she worked about three times per week for the last two weeks at the facility. RN 3 stated that she had not been involved in an admission process. RN 3 stated that usually other nurses helped her with questions about admissions. RN 3 stated that orders were sent to the the facility to enter into the electronic medical record. RN 3 sated she did not know if there was a process to double check new admission orders. RN 3 stated if a resident had an allergy it was listed at the top of the MAR screen in the electronic medical record. RN 3 stated when orders were already entered into the electronic medical record, she trusted that it was all correct. RN 3 stated that the electronic medical record did not flag or create a warning that the resident was allergic to a medication. RN 3 stated that an order was entered incorrectly for resident 195. RN 3 stated she did not know that resident 195 had a allergy or that there was a problem until talking with the Nurse Practitioner (NP) on 8/15/21. RN 3 stated that she administered Tizanidine before the Lortab. RN 3 stated she told the NP that the resident was not doing very good. RN 3 stated that resident 195 was walking with someone and became dizzy and was unstable on her feet. RN 3 stated that resident 195 was taken to bed. RN 3 stated At that point I noticed something. RN 3 stated that resident 195 was very lethargic, slurring her speech, saying silly things, and asking if this was what a drug addict felt like. RN 3 stated she told the NP that she administered Lortab to resident 195 which was ordered in the electronic medical record. RN 3 stated she provided a liter of Normal Saline through an IV and administered Narcan. RN 3 stated that resident 195's BP did not go up and her BP was not reading manually or on the electronic machine. RN 3 stated resident 195 was awake and able to answer questions but was trying to fall asleep. RN 3 stated that she talked to resident 195 and told her to stay awake. RN 3 stated that resident was a full code and EMS was called. RN 3 stated that she thought the Lortab and Tizanidine caused resident 195's blood pressure to drop. [Note: Resident 195 was administered Tizanidine on 8/14/21 and did not have a documented low blood pressure reaction.] On 8/18/21 at 2:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a central intake department entered the physician's orders for new admission residents into the electronic medical record. The DON stated the resident's nurse then reviewed the orders and ensured they were put in properly. The DON stated that central intake entered allergies into the electronic medical record. The DON stated that central intake fixed any questions. The DON stated that sometimes central intake entered in an allergy and clarified what happened as result of an allergy. The DON stated that RN 3, an agency nurse, administered a Lortab to resident 195. The DON stated that RN 3 had not realized resident 195 had an allergy. The DON stated that RN 3 had Lortab as an allergy. The DON stated that RN 3 notified the physician and administered 1 liter of fluid and Narcan. The DON stated that resident 195's blood pressure was still low after the 1 bag of fluid. The DON stated that RN 3 called the physician again and resident 195 was sent to the ED via EMS. The DON stated that the resident 195 was administered another liter of fluid and given orders to hold blood pressure medications. The DON stated that after the nurse administered the Lortab, she planned on providing education to nursing staff to slow down and ensure the were giving proper medications. The DON stated an inservice would be provided the following week to double check medications entered, and that night shift would review the medications as well. POTENTIAL FOR HARM 2. Resident 28 was admitted on [DATE] with diagnoses which included chronic inflammatory demyelinating polyneuritis, acute kidney failure, pressure ulcer of left heel, hyperkalemia, severe protein-calorie malnutrition, type 2 diabetes mellitus without complications, and end stage renal disease with dialysis. On 8/16/21 at approximately 12:00 PM, an interview was conducted with resident 28. Resident 28 stated that she had a medication that needed to be administered when she was eating. Resident 28 stated that the medication was to help her digest food so taking it before or after the meal was not effective. Resident 28 stated that her medication was frequently 2 hours late. Resident 28's medical record was reviewed on 8/18/21. A physician's order dated 7/22/21 revealed Sevelamer HCL 800mg to administer with meals. According to the August 2021 MAR Sevelamer was administered the following dates and times: a. 8/1/21 the 8:00 AM dose was refused at 10:33 AM. b. 8/7/21 the 8:00 AM dose was administered at 9:57 AM. c. 8/10/21 the 8:00 AM dose was administered at 9:49 AM. d. 8/10/21 the 12:00 PM dose was administered at 4:32 PM. The reason documented was flex. e. 8/11/21 the 12:00 PM dose was administered at 1:06 PM. f. 8/13/21 the 8:00 AM dose was administered at 9:30 AM. g. 8/13/21 the 12:00 PM dose was administered at 1:17 PM. h. 8/14/21 the 8:00 AM dose was administered at 11:27 AM. i. 8/14/21 the 12:00 PM dose was administered at 1:01 PM. j. 8/15/21 the 5:30 PM dose was administered at 9:56 PM. k. 8/17/21 the 12:00 PM dose was refused at 2:21 PM. A dietary progress note dated 7/30/21 at 7:32 PM revealed, Nutrition assessment summary and recommendations: .Pt receiving renal MVI (multivitamin) for repletion and Sevelamer as phosphorus binder. Rec (Recommend) providing phosphorus binder within 5 min of meals to be most effective. Will cont (continue) to monitor and f/u (follow up) prn (as needed). On 8/19/21 at 9:07 AM, an interview was conducted with RN 1. RN 1 stated resident 28 had 2 tablets of phosphate binder that was to be taken with breakfast and lunch and 1 tablet with dinner. RN 1 stated that the phosphate binders were not given because resident 28 was out of the facility at appointments. RN 1 stated that resident 28 had an order to send medications with her when the resident was out of facility for appointments so the medication was taken when she ate.