**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice during medication administration for one of five residents in the survey sample (Resident #1), resulting in an opioid overdose, which required hospitalization. The findings include: Registered nurse (RN) #1 failed to compare the morphine on-hand to Resident #1's physician's order prior to giving the medication, resulting in the administration of a 100 mg (milligram) dose, rather than the 10 mg dose ordered by the physician. Recognition that a higher concentration of liquid morphine was selected than that listed on the physician's order was not made until after administration of the medication. Resident #1 experienced an emergency transfer and hospitalization for treatment of the medication overdose. Resident #1 was admitted to the facility with diagnoses that included lung cancer, chronic respiratory failure, dementia with behaviors, gastroenteritis, dermatitis, bronchitis, depression, insomnia, history of pneumonia and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #1 with severely impaired cognitive skills. Nursing notes on 2/9/23 documented, .resident continues to be declining, continues to have SOB [shortness of breath] even with cont. [continuous] oxygen at 3L [liters per minute] and scheduled breathing treatments .MD [physician] notified of current condition, New orders obtained to increase prednisone .New order for morphine 10 mg PRN q 4hrs [as needed every 4 hours] for SOB .[3:06 p.m.] .Spoke with MD and RP and in agreement to give morphine for SOB . Resident #1's clinical record documented a physician's order dated 2/9/23 for morphine solution 10 mg/ 5 ml (milliliters) amount to give 10 mg orally every 4 hours as needed for shortness of breath. A nursing note, dated 2/10/23 at 9:56 a.m. documented, This nurse notified of wrong dose given: MD and RP [responsible party] were notified. MD gave order to send to ED [emergency department] for eval. [evaluation] VS [vital signs]: 100/70 BP [blood pressure] and O2 [oxygen saturation] 97 on 2L [liters per minute]. VS then checked again [BP] 80/58 [O2 sat] 87 [oxygen saturation at] 2L. EMS was called. Resident was remaining alert and talking drinking well .SOB had resolved . The emergency department record dated 2/10/23 documented, . per EMS, patient was given 100 mg liquid morphine instead of the prescribed dose of 10 mg morphine. Given at approx [approximately] 0940 [9:40 a.m.]. pt [patient] was given Narcan enroute . The emergency department history documented, .presents to the ED somnolent, obtunded that has improved after Narcan administration at 1021 [10:21 a.m.]. Patient as [was] accidentally overdosed on morphine given at the .nursing home. Yesterday on 2/9/23, patient was prescribed Morphine 10 mg/5 ml solution. He is dosed to get 10 mg every 4 hours for shortness of breath. Patient was given 100 mg this morning at 0945 [ 9:45 a.m.]. Patient is demented at baseline and cannot contribute to much of this history besides denying chest pain, abdominal pain, shortness of breath . Per the hospital documentation, Resident #1 was administered a second dose of Narcan in the emergency department and was admitted to the intensive care unit for continued Narcan administration and monitoring. Resident #1 discharged back to the nursing home on 2/11/23. The hospital Discharge summary dated [DATE] documented, .with advanced dementia chronic hypoxic respiratory failure and lung cancer having declined any further work-ups or treatments being conservatively managed at .nursing home had an order at the facility for 10 mg of oral morphine was accidentally given at 100 mg. Got Narcan in route from EMS. Upon arrival to the emergency department was hemodynamically stable .Started on Narcan drip due to the amount of opiates. Protecting his airway. Narcan drip turned things around nicely .Awake oriented to his baseline .Stable for discharge to skilled facility . Resident #1 was re-admitted to the facility on [DATE], with the orders for prednisone and morphine discontinued. A nursing note on 2/11/23 documented, .Resident noted to have a lot of fluid in face/hands/arms .very wet gurgly breathing when lying flat, resident with head up did not sound wet .Resident O2 obtained and noted at 64%, oxygen at 4L came up to 86%. Order obtained to send resident back to ED . Per hospital documentation, Resident #1 was re-admitted to the hospital on [DATE] for acute/chronic respiratory failure with hypoxemia, aspiration pneumonitis, accidental overdose, and possible sepsis. The facility summary dated 2/10/23 documented that Resident #1 was administered an incorrect dose of morphine and was admitted to the hospital on [DATE] for treatment of the overdose. The facility's synopsis of the 2/10/23 overdose, dated 2/14/23, documented, .it was determined [Resident #1] was administered 100 mgs of Morphine when he should have received 10 mgs of Morphine. This medication error occurred as a result of [RN #1] entering the room to assess another issue .[Resident #1] began to yell out 'I can't Breathe' .[Resident #1] received a breathing treatment and was still showing no signs of relief. [Resident #1] was transferred to w/c [wheelchair] for upright sitting position, still no signs of relief .had a new order for morphine on 2/9/23 for shortness of breath. The medication had not been received from pharmacy .[RN #1] and [licensed practical nurse #1] immediately went to the Pyxis system and pulled morphine from the emergency supply. 5 ml was drawn per the order .was administered to [Resident #1]. [RN #1] returned to the med [medication] cart upon preparing to document dosage, [RN #1] realized a different formulary was in our Pyxis from the MD order. The order was for 10 mg per 5 ml and our emergency supply was 100 mg per 5 ml .Narcan was on hand but not administered as [Resident #1] showed no symptoms and remained asymptomatic while waiting on first responders. [Resident #1] was transported to the ER [emergency room] .returned to the facility on 2/11/23 .was sent back to the ER .due to low O2 saturation and respiratory distress .Education has been provided to [RN #1] to verify strength of stat morphine pulled per MD order to determine if conversion of dosage is required . On 2/15/23 at 11:30 a.m., RN #1, who administered the 100 mg dose of morphine to Resident #1, was interviewed. RN #1 stated that licensed practical nurse (LPN) #1 asked her to assess the resident #1's left eye redness. RN #1 stated she and LPN #3 went to the resident #1's room to assess the eye on the morning of 2/10/23. RN #1 stated that while the aides were performing incontinence care, she observed Resident #1 was visibly short of breath and gurgling. RN #1 stated that they sat the resident up, adjusted his oxygen, and LPN #3 administered a prescribed breathing treatment. RN #1 stated that the breathing treatment provided little relief with the resident #1 stating he could not breath. RN #1 stated that she went to LPN #1 to get the morphine prescribed for shortness of breath, but LPN #1 informed her the prn morphine order was entered yesterday (2/9/23) and had not arrived yet from pharmacy. RN #1 stated that she and LPN #1 went to the emergency supply device (Pyxis) to obtain oral morphine for Resident #1. RN #1 stated that she retrieved a 30 ml bottle of oral morphine solution from the emergency supply, returned to the medication cart, looked at the medication order on the medication administration record (MAR) that listed the concentration of 10 mg/5 ml and to give 10 mg. RN #1 stated that she poured 5 ml from the bottle of morphine into a medicine cup, went to LPN #1, and asked her to verify the 5 ml. RN #1 stated that she went to the resident #1's room, verified there was 5 ml in the medicine cup with LPN #3, and then administered the medication to Resident #1. RN #1 stated that she went back to the medication cart to document the administration, looked at the bottle of morphine used and realized I gave 100 mg instead of 10 mg. RN #1 stated that when she looked at the label to document the administration, she recognized the error, and immediately knew she had given the wrong dose. RN #1 stated she told LPN #1 that she had given the resident too much morphine. RN #1 stated Narcan was on hand and LPN #3 monitored the resident's vital signs until EMS arrived. RN #1 stated the resident was alert at baseline and was transferred to the hospital for evaluation and treatment. RN #1 stated concerning the error, I did not confirm the dose on the bottle with the order on the MAR. I was trying to get it [morphine] to him as quick as I could because he was in respiratory distress. RN #1 stated she had LPN #1 and LPN #3 verify that she had 5 ml in the medicine cup, but she nor the other nurses compared the bottle label to the order. RN #1 stated the 100 mg/5 ml concentration was the usual supply in the Pyxis. RN #1 stated that she failed to compare the label on the bottle of morphine to the physician's order until after she administered the medication. RN #1 stated that she looked only at the order and was thinking 5 ml when she prepared the medicine. RN #1 stated that if she had compared the medicine label to the order, she would have known to only give 0.5 ml of the 100 mg/5 ml concentration, instead of 5 ml. On 2/15/23 at 11:30 a.m., LPN #1 was interviewed about Resident #1's medication error of 2/10/23. LPN #1 stated that RN #1 reported to her that resident #1 was short of breath and she needed the prn morphine. LPN #1 stated she went with RN #1 to the emergency supply device and assisted her with retrieving the bottle of morphine. LPN #1 stated she never reviewed the order and did not witness RN #1 pour the medication. LPN #1 stated she verified that 5 ml was in the medicine cup. LPN #1 stated, I never saw the order. I didn't know how the order read. I did not look at the label on the bottle. LPN #1 stated that RN #1 came to her a few minutes later and stated she had given Resident #1 too much morphine. On 2/15/23 at 11:52 a.m., LPN #3 that was with RN #1 during the morphine administration was interviewed. LPN #3 stated that she went with RN #1 to assess a reported eye issue with Resident #1 and as the aides were changing him, resident #1 became short of breath. LPN #3 stated that she administered a breathing treatment in addition to adjusting oxygen and sitting the resident upright. LPN #3 stated that resident #1 still had breathing difficulty, despite the interventions, and RN #1 left the room to get the morphine. LPN #3 stated RN #1 came back into the resident's room with the dose of oral morphine and said the dose was 10 mg. LPN #3 stated, I said yes, 10 mg. I put the order in the day before. LPN #3 stated that she did not look at the bottle of morphine used for the dose, but she witnessed RN #1 administer the oral solution to Resident #1. LPN #3 stated that RN #1 came to her a few minutes later and said that she had given the wrong dose of morphine. LPN #3 stated that Narcan was retrieved from the Pyxis emergency supply but the physician ordered to immediately send the resident to the emergency room. LPN #3 stated that she monitored the resident continuously until EMS arrived and the resident was alert and talking. LPN #3 stated the 100 mg/5 ml morphine concentration was the usual dosage provided in the emergency supply. On 2/15/23 at 2:07 p.m., the director of nursing (DON) was interviewed about Resident #1's morphine dosage error. The DON stated that she was off on 2/10/23 but RN #1 called her, reported she made a mistake, and that she had administered Resident #1 a 100 mg dose of morphine instead of the ordered 10 mg. The DON stated that Narcan was available, the physician notified, and the resident sent to the hospital for treatment. When questioned further, the DON stated there had been no medication errors in the facility for at least the past year. The DON stated that there was no history of any medication errors or care concerns involving RN #1. The DON stated that she told RN #1 not to administer anymore medications on 2/10/23 because of the error and that RN #1 had been upset about the incident. The DON stated that RN #1 was educated on 2/13/23 about always checking to ensure the correct dosage and compliance with the physician's order when retrieving/administering medications from the emergency supply. When questioned about the proper procedure, the DON stated that RN #1 should have compared the bottle label to the order prior to administration of morphine to the resident and that RN #1 failed to compare the order to the concentration that was available in the emergency supply. The DON stated that if unsure or if there were any questions about dosing, especially regarding an opioid, nurses had access to the pharmacy and could also call the provider for clarification. The DON stated this error was made because the nurse failed to compare the label to the order, adjust the amount given, and/or seek clarification about the dosing prior to administration of the medicine. The DON stated in this situation that Resident #1 was having difficulty breathing and, in human error, RN #1 did not look at the concentration of the morphine that she was administering. The DON stated that RN #1 did not typically work on the floor but .jumped in to help. When asked, the DON stated that this error was preventable if the label and order had been compared and adjustments and/or clarification made prior to preparing and administering the medicine. On 2/16/23 at 10:45 a.m., RN #1 was interviewed again about the medication error. RN #1 stated that there was no issue with calculating the proper dose. RN #1 stated that in the heat of the moment she was trying to get the medication to the resident quickly due his respiratory distress. RN #1 stated that she was assuming she had the concentration on the order instead of actually checking the label. RN #1 stated with the 100 mg/5 ml concentration from the emergency supply, she should have administered 0.5 ml instead of 5 ml. RN #1 stated, It was an oversight on my part. On 2/16/23 at 11:20 a.m., the consultant pharmacist (other staff #1) was interviewed about the Resident #1's medication error. The pharmacist stated that the 30 ml bottle of morphine solution with the 100 mg/5 ml concentration was the only concentration available for supply in the emergency Pyxis device. The pharmacist stated that consultation was available to nursing 24 hours per day if there was a question about dosage or amounts to administer. The pharmacist stated that the 10 mg dose of morphine could have been administered correctly from the bottle of 100 mg/5 ml, if 0.5 ml was administered. The facility's policy titled Medication Administration - General Guidelines (effective 10/1/17) documented, Medications are administered as prescribed in accordance with good nursing principles and practices . Step 4 of the policy documented regarding the eight rights of medication administration, EIGHT RIGHTS - Right resident, right drug, right dose, right route, right time, right documentation, right reason, right response, are applied for each medication being administered. A triple check of the first 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away .Check #1: Select the Medication - label, container, and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the first 5 Rights .Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the first 5 Rights .Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the first 5 Rights .The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident medication administration schedule (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule . The facility's policy titled Oral Medication Administration (effective 6/9/15) documented in procedures for administering medications, .Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medications to each resident . The Nursing 2022 Drug Handbook on page 1004 describes morphine as an opioid analgesic used for the management of moderate to severe pain. This reference documents oral morphine has a black box warning stating, Take care when administering morphine oral solution to avoid dosing errors because of confusion among different concentrations and between milligrams and milliliters, which could result in accidental overdose and death . (1) The following QAPI Action Plan, dated 3-14-23, was provided for review: Resident sent to ER for evaluation following accidental Morphine overdose 1. Correction for identified resident/system - resident sent to ER for evaluation 2. How will you identify other potential residents and correct them if needed? - Audit was performed for any Morphine pulled from Pyxis system for resident use in the last 30 days with no other residents identified. 3. System Changes: what are you going to do differently to minimize recurrence? - all Morphine take from Pyxxis require 2 nurses to pull. Additional changes both nurses will review Morphine at med cart with MAR to ensure proper dosage pulled prior to administering Morphine. Education provided to all nurses by DON/designee. 4. Monitoring - RN supervisor or designee to audit Pyxis system to ensure 2 nurses to verify with MAR prior to administering Morphine. Weekly audits x 12 weeks x 3 months. Audits will be reviewed in monthly QA meetings for review/recommendations. These findings were reviewed with the administrator and director of nursing on 2/16/23 at 11:50 a.m. Subsequently, evidence of nursing education was requested and provided. Based on facility documentation, a determination of Past Noncompliance was made. (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure one of five residents (Resident #1) was free from a significant medication error, which resulted in an opioid overdose requiring hospitalization. The findings include: Resident #1 was administered a 100 mg (milligram) dose of oral morphine solution, ten times the physician's order that required a 10 mg dose. The medication error resulted in an emergency transfer and hospitalization of Resident #1 for treatment of the overdose. Registered nurse (RN) #1 failed to compare the morphine on-hand to Resident #1's physician's order prior to giving the medication resulting in the administration of a 100 mg (milligram) dose rather than the 10 mg dose ordered by the physician. Recognition that a higher concentration of liquid morphine was used than that listed on the physician's order was not made until after administration of the medication. Resident #1 was admitted to the facility with diagnoses that included lung cancer, chronic respiratory failure, dementia with behaviors, gastroenteritis, dermatitis, bronchitis, depression, insomnia, history of pneumonia and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #1 with severely impaired cognitive skills. Nursing notes on 2/9/23 documented, .resident continues to be declining, continues to have SOB [shortness of breath] even with cont. [continuous] oxygen at 3L [liters per minute] and scheduled breathing treatments .MD [physician] notified of current condition, New orders obtained to increase prednisone .New order for morphine 10 mg PRN q 4hrs [as needed every 4 hours] for SOB .[3:06 p.m.] .Spoke with MD and RP and in agreement to give morphine for SOB . Resident #1's clinical record documented a physician's order dated 2/9/23 for morphine solution 10 mg/ 5 ml (milliliters) amount 10 mg orally every 4 hours as needed for shortness of breath. A nursing noted on 2/10/23 at 9:56 a.m. documented, This nurse notified of wrong dose given: MD and RP [responsible party] were notified. MD gave order to send to ED [emergency department] for eval. [evaluation] VS [vital signs]: 100/70 BP [blood pressure] and O2 [oxygen saturation] 97 on 2L [liters per minute]. VS then checked again [BP] 80/58 [O2 sat] 87 [oxygen saturation at] 2L. EMS was called. Resident was remaining alert and talking drinking well .SOB had resolved . The emergency department record dated 2/10/23 documented, . per EMS, patient was given 100 mg liquid morphine instead of the prescribed dose of 10 mg morphine. Given at approx [approximately] 0940 [9:40 a.m.]. pt [patient] was given Narcan enroute . The emergency department history documented, .presents to the ED somnolent, obtunded that has improved after Narcan administration at 1021 [10:21 a.m.]. Patient as [was] accidentally overdosed on morphine given at the .nursing home. Yesterday on 2/9/23, patient was prescribed Morphine 10 mg/5 ml solution. He is dosed to get 10 mg every 4 hours for shortness of breath. Patient was given 100 mg this morning at 0945 [ 9:45 a.m.]. Patient is demented at baseline and cannot contribute to much of this history besides denying chest pain, abdominal pain, shortness of breath . Resident #1 was administered a second dose of Narcan in the emergency department and was admitted to the intensive care unit for continued Narcan administration and monitoring. Resident #1 discharged back to the nursing home on 2/11/23. The hospital Discharge summary dated [DATE] documented, .with advanced dementia chronic hypoxic respiratory failure and lung cancer having declined any further work-ups or treatments being conservatively managed at .nursing home had an order at the facility for 10 mg of oral morphine was accidentally given at 100 mg. Got Narcan in route from EMS. Upon arrival to the emergency department was hemodynamically stable .Started on Narcan drip due to the amount of opiates. Protecting his airway. Narcan drip turned things around nicely .Awake oriented to his baseline .Stable for discharge to skilled facility . The resident was re-admitted to the facility on [DATE] with orders for prednisone and morphine discontinued. A nursing note on 2/11/23 documented, .Resident noted to have a lot of fluid in face/hands/arms .very wet gurgly breathing when lying flat, resident with head up did not sound wet .Resident O2 obtained and noted at 64%, oxygen at 4L came up to 86%. Order obtained to send resident back to ED . Per hospital documentation, Resident #1 was re-admitted to the hospital on [DATE] for acute/chronic respiratory failure with hypoxemia, aspiration pneumonitis, accidental overdose, and possible sepsis. A facility summary of 2/10/23 documented that Resident #1 was administered an incorrect dose of morphine and was admitted to the hospital on [DATE] for treatment of the overdose. The facility's synopsis of the 2/10/23 overdose, dated 2/14/23 documented, .it was determined [Resident #1] was administered 100 mgs of Morphine when he should have received 10 mgs of Morphine. This medication error occurred as a result of [RN #1] entering the room to assess another issue .[Resident #1] began to yell out 'I can't Breathe' .[Resident #1] received a breathing treatment and was still showing no signs of relief. [Resident #1] was transferred to w/c [wheelchair] for upright sitting position, still no signs of relief .had a new order for morphine on 2/9/23 for shortness of breath. The medication had not been received from pharmacy .[RN #1] and [licensed practical nurse #1] immediately went to the Pyxis system and pulled morphine from the emergency supply. 5 ml was drawn per the order .was administered to [Resident #1]. [RN #1] returned to the med [medication] cart upon preparing to document dosage, [RN #1] realized a different formulary was in our Pyxis from the MD order. The order was for 10 mg per 5 ml and our emergency supply was 100 mg per 5 ml .Narcan was on hand but not administered as [Resident #1] showed no symptoms and remained asymptomatic while waiting on first responders. [Resident #1] was transported to the ER [emergency room] .returned to the facility on 2/11/23 .was sent back to the ER .due to low O2 saturation and respiratory distress .Education has been provided to [RN #1] to verify strength of stat morphine pulled per MD order to determine if conversion of dosage is required . On 2/15/23 at 11:30 a.m., RN #1, who administered the 100 mg dose of morphine to Resident #1, was interviewed. RN #1 stated that licensed practical nurse (LPN) #1 asked her to assess the resident #1's left eye redness. RN #1 stated she and LPN #3 went to the resident #1's room to assess the eye on the morning of 2/10/23. RN #1 stated that while the aides were performing incontinence care, she observed Resident #1 was visibly short of breath and gurgling. RN #1 stated that they sat the resident up, adjusted his oxygen, and LPN #3 administered a prescribed breathing treatment. RN #1 stated that the breathing treatment provided little relief with the resident #1 stating he could not breath. RN #1 stated that she went to LPN #1 to get the morphine prescribed for shortness of breath, but LPN #1 informed her the prn morphine order was entered yesterday (2/9/23) and had not arrived yet from pharmacy. RN #1 stated that she and LPN #1 went to the emergency supply device (Pyxis) to obtain oral morphine for Resident #1. RN #1 stated that she retrieved a 30 ml bottle of oral morphine solution from the emergency supply, returned to the medication cart, looked at the medication order on the medication administration record (MAR) that listed the concentration of 10 mg/5 ml and to give 10 mg. RN #1 stated that she poured 5 ml from the bottle of morphine into a medicine cup, went to LPN #1, and asked her to verify the 5 ml. RN #1 stated that she went to the resident #1's room, verified there was 5 ml in the medicine cup with LPN #3, and then administered the medication to Resident #1. RN #1 stated that she went back to the medication cart to document the administration, looked at the bottle of morphine used and realized I gave 100 mg instead of 10 mg. RN #1 stated that when she looked at the label to document the administration, she recognized the error, and immediately knew she had given the wrong dose. RN #1 stated she told LPN #1 that she had given the resident too much morphine. RN #1 stated Narcan was on hand and LPN #3 monitored the resident's vital signs until EMS arrived. RN #1 stated the resident was alert at baseline and was transferred to the hospital for evaluation and treatment. RN #1 stated concerning the error, I did not confirm the dose on the bottle with the order on the MAR. I was trying to get it [morphine] to him as quick as I could because he was in respiratory distress. RN #1 stated she had LPN #1 and LPN #3 verify that she had 5 ml in the medicine cup, but she nor the other nurses compared the bottle label to the order. RN #1 stated the 100 mg/5 ml concentration was the usual supply in the Pyxis. RN #1 stated that she failed to compare the label on the bottle of morphine to the physician's order until after she administered the medication. RN #1 stated that she looked only at the order and was thinking 5 ml when she prepared the medicine. RN #1 stated that if she had compared the medicine label to the order, she would have known to only give 0.5 ml of the 100 mg/5 ml concentration, instead of 5 ml. On 2/15/23 at 11:30 a.m., LPN #1 was interviewed about Resident #1's medication error of 2/10/23. LPN #1 stated that RN #1 reported that resident #1 was short of breath and she needed the morphine. LPN #1 stated that she went with RN #1 to the emergency supply device and assisted her with retrieving the bottle of morphine. LPN #1 stated that she never reviewed the order and did not witness RN #1 pour the medication. LPN #1 stated that she verified that 5 ml was in the medicine cup. LPN #1 stated, I never saw the order. I didn't know how the order read. I did not look at the label on the bottle. LPN #1 stated that RN #1 came to her a few minutes later and stated she had given Resident #1 too much morphine. On 2/15/23 at 11:52 a.m., LPN #3 that was with RN #1 during the morphine administration was interviewed. LPN #3 stated that she went with RN #1 to assess a reported eye issue with Resident #1 and as the aides were changing him, the resident became short of breath. LPN #3 stated that she administered a breathing treatment in addition to adjusting oxygen and sitting the resident upright. LPN #3 stated that the resident still had breathing difficulty despite the interventions and RN #1 left the room to get the as needed morphine. LPN #3 stated that RN #1 came back into the resident's room with the dose of oral morphine and said the dose was 10 mg. LPN #3 stated, I said yes, 10 mg. LPN #3 stated, I put the order in the day before. LPN #3 stated that she did not look at the bottle of morphine used for the dose, and she witnessed RN #1 administer the oral solution to Resident #1. LPN #3 stated that RN #1 came to her a few minutes later and said that she had given the wrong dose of morphine. LPN #3 stated the Narcan was retrieved from the Pyxis emergency supply, but the physician stated to immediately send the resident to the emergency room. LPN #3 stated that she monitored the resident continuously until EMS arrived and the resident #1 was alert and talking. LPN #3 stated the 100 mg/5 ml morphine concentration was the usual provided in the emergency supply. On 2/15/23 at 2:07 p.m., the director of nursing (DON) was interviewed about Resident #1's morphine dosage error. The DON stated that she was off on 2/10/23, but RN #1 called her, reported she made a mistake, and that she had administered Resident #1 a 100 mg dose of morphine instead of the ordered 10 mg. The DON stated Narcan was available, the physician notified, and the resident sent to the hospital for treatment. The DON stated there had been no medication errors in the facility for at least the past year. The DON stated there was no history of any medication errors or care concerns involving RN #1. The DON stated that she told RN #1 not to administer anymore more medications on 2/10/23 because of the error and because RN #1 was upset about the incident. The DON stated RN #1 was educated on 2/13/23 about always checking to ensure the correct dosage and compliance with the physician's order when retrieving/administering medications from the emergency supply. When questioned, the DON stated that RN #1 should have compared the bottle label to the order prior to administration of morphine to the resident. The DON stated that RN #1 failed to compare the order to the concentration that was available in the emergency supply. The DON stated if unsure, or if there were any questions about dosing, especially regarding an opioid, nurses had access to pharmacy and could call the provider for clarification. The DON stated that this error was made because the nurse failed to compare the label to the order, adjust the amount given and/or seek clarification about the dosing prior to administration of the medicine. The DON stated that in this situation the resident was having difficulty breathing and in human error, the nurse did not look at the concentration of the morphine she was administering. The DON stated that RN #1 did not typically work on the floor but jumped in to help. The DON stated that this error was preventable if the label and order had been compared and adjustments and/or clarification made prior to preparing and administering the medicine. On 2/16/23 at 10:45 a.m., RN #1 was interviewed again about the medication error. When questioned further, RN #1 stated there was no issue with calculating the proper dose. RN #1 stated in the heat of the moment she was trying to get the medication to the resident quickly due his respiratory distress. RN #1 stated she was assuming she had the concentration on the order, instead of actually checking the label. RN #1 stated that with the 100 mg/5 ml concentration from the emergency supply, she should have administered 0.5 ml instead of 5 ml. RN #1 stated, It was an oversight on my part. On 2/16/23 at 11:20 a.m., the consultant pharmacist (other staff #1) was interviewed about the Resident #1's medication error. The pharmacist stated that the 30 ml bottle of morphine solution with the 100 mg/5 ml concentration was the only concentration available for supply in the emergency Pyxis device. The pharmacist stated that consultation was available to nursing 24 hours per day if there was a question about dosage or amounts to administer. The pharmacist stated that the 10 mg dose of morphine could have been administered correctly from the bottle of 100 mg/5 ml bottle if 0.5 ml were administered. The facility's policy titled Medication Administration - General Guidelines (effective 10/1/17) documented, Medications are administered as prescribed in accordance with good nursing principles and practices . Step 4 of the policy documented regarding the eight rights of medication administration, EIGHT RIGHTS - Right resident, right drug, right dose, right route, right time, right documentation, right reason, right response, are applied for each medication being administered. A triple check of the first 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away .Check #1: Select the Medication - label, container, and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the first 5 Rights .Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the first 5 Rights .Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the first 5 Rights .The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident medication administration schedule (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule . The facility's policy titled Oral Medication Administration (effective 6/9/15) documented in procedures for administering medications, .Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medications to each resident . The Nursing 2022 Drug Handbook on page 1004 describes morphine as an opioid analgesic used for the management of moderate to severe pain. This reference documents oral morphine has a black box warning stating, Take care when administering morphine oral solution to avoid dosing errors because of confusion among different concentrations and between milligrams and milliliters, which could result in accidental overdose and death . (1) The following QAPI Action Plan, dated 3-14-23, was provided for review: Resident sent to ER for evaluation following accidental Morphine overdose 1. Correction for identified resident/system - resident sent to ER for evaluation 2. How will you identify other potential residents and correct them if needed? - Audit was performed for any Morphine pulled from Pyxis system for resident use in the last 30 days with no other residents identified. 3. System Changes: what are you going to do differently to minimize recurrence? - all Morphine take from Pyxxis require 2 nurses to pull. Additional changes both nurses will review Morphine at med cart with MAR to ensure proper dosage pulled prior to administering Morphine. Education provided to all nurses by DON/designee. 4. Monitoring - RN supervisor or designee to audit Pyxis system to ensure 2 nurses to verify with MAR prior to administering Morphine. Weekly audits x 12 weeks x 3 months. Audits will be reviewed in monthly QA meetings for review/recommendations. These findings were reviewed with the administrator and director of nursing on 2/16/23 at 11:50 a.m. Subsequently, evidence of nursing education was requested and provided. Based on facility documentation, a determination of Past Noncompliance was made. (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to use footrest and a foot board/plate on a wheelchair to prevent accidents resulting in a clavicle fracture for one of 21 residents in the survey sample, Resident #15; and failed to ensure physician orders and ensure an assessment was completed for the use of a Broda specialized wheelchair, for one of 21 residents sample, Resident #37. The findings include: 1. Resident #15 was originally admitted on [DATE] with diagnoses that included Alzheimer' disease, acute embolism and thrombosis of deep veins - left lower extremity, edema, bipolar disorder, cardiac murmur, depression, hypertension and constipation. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #15 has having long and short term memory problems, moderately impaired for daily decision making and have continuous periods of inattention and disorganized thinking. Section G - Functional Status on the MDS assessed Resident #15 as requiring extensive assistance, with one person physical assistance for bed mobility, total dependence, with one personal physical assistance for toileting, hygiene, dressing, locomotion, and transfers. On 09/03/19 at 11:15 a.m., during the initial tour, Resident #15's daughter was interviewed regarding Resident #15's quality of life and care since being admitted at the facility. The daughter stated Resident #15 had recently had a fall resulting in a hematoma and bruising. She stated this past weekend we were notified that she has a fractured clavicle from the last fall. Resident #15's daughter was asked if she knew how the fall occurred. She stated she was told the resident fell out of the wheelchair. Resident #15's daughter pointed towards the wheelchair and stated I do see they have placed a larger footboard on the bottom of the wheelchair. I always thought the other one was too small. Resident #15's clinical record was reviewed on 09/04/19 at 1:45 p.m. Observed were the following nurses' notes: 08/21/19 18:48 Nurse was off unit when CNA notified writer of fall event. Nurse assessed resident and noted large hematoma to right side of forehead with minimal bleeding from small laceration. Nurse noted CNA had applied ice compact for swelling and to control bleeding prior to nurse arrival. Resident denied pain during assessment. [Name of Physician], DON (director of nursing) and family notified of fall. Per MD (Doctor) instructions, resident was sent to ER (emergency room) for an evaluation . 08/21/19 23:36 Writer spoke with [Name of ER Nurse]. Writer was informed that resident had head and spine CT with no fractures. Resident has large hematoma to right forehead where Derma-Bond was applied for adhesiveness. Writer instructed to hold Eliquis for 24 hours and notified MD r/t (related to fall) history and to continue or D/C (discontinue) medication. Resident arrived in good spirit and alert, oriented to baseline. Resident is able to express pain and discomfort to staff. Will continue to monitor. 08/22/19 13:47 [Name of Physician Assistant] into see resident this shift, Order to d/c Eliquis and ordered Doppler to both lower extremities. Rp [name] notified at this time. 08/22/19 22:26 Resident continues s/p fall .resident slides down in chair daily. Staff adjusted resident several times today. PT (physical therapy) eval (evaluation) in place for positioning. 08/26/19 6:36 observed resident right shoulder swollen bruised uneven bilateral denies pain and discomfort, will notify MD. 08/26/19 15:57 MD was informed of swelling and bruising to (R) shoulder. Resident was seen by MD. MD did not want F/U (follow-up) x-ray at this time d/t (due to) resident denies pain in area. Will continue to monitor. 08/26/19 22:21 Nurse noted bruising to right shoulder per shift possibly r/t S/P fall. No grimace, noted pain or discomfort. Will continue to monitor. 08/27/19 6:13 Continues with noted bruising to right shoulder. No c/o pain. No s/s of distress. Resting quietly throughout shift. 08/28/19 10:55 Weekly Standards of Care meeting held today with IDT (interdisciplinary) team present, discussed Fall on 08/21/19 out of chair, hematoma to right forehead, small laceration and sent to ER for eval per orders. Derma-bond applied in ED, CT can of head and spine completed with negative results received. Intervention PT and OT eval. No other issues noted. Continue current POC (plan of care). 08/29/19 6:39 Weekly Skin Assessment completed. Fading bruising continues to right shoulder .Will continue to monitor. 08/29/19 19:36 Resident noted to have swelling and bruising to right shoulder. Resident was seen by MD today and x-ray ordered r/t recent fall. RP notified [name]. facility awaiting results. 08/30/19 14:22 X-ray results obtained and show a non-displaced acute fx (fracture) through the distal clavicle and that the AC joint is well maintained. MD was notified and gave an order for a non-urgent follow-up with Ortho in 7-10 days. Resident continues to deny pain, ROM is WNL, bruising continues. This nurse left message for residents RP to call facility. Will continue to monitor resident for pain and discomfort. A review of the 08/30/19 x-ray documented: Right Shoulder 2 View. History: related to fall. Findings: internal and external rotation views show nondisplaced acute fracture through the distal end of the right clavicle. The AC joint is well maintained . On 09/04/19 at 2:30 p.m., MDS coordinator (RN #1) who documented the note on 08/28/19 regarding the Weekly Standards of Care meeting was interviewed. RN #1 stated after the IDT discussed that due to Resident #15 having falls on 06/20/19, 07/16/19 and 8/21/19 the IDT felt is was best to have a PT/OT evaluation to assist with possible other fall interventions. On 09/04/19 at 2:45 p.m., the rehab manager (OS #2) was interviewed regarding the PT/OT evaluation. OS #2 provided a copy of the evaluation that took place on 08/29/19. Observed on the OT evaluation was the following: Patient referred to skilled OT services due to recent fall out of wheelchair. Patient is an [AGE] year old female resident at [name of facility]. Patient referred to skilled OT services due to recent fall out of wheelchair on 08/21/19 caused by not having foot rests and back plate on wheelchair. Intervention in place at this time to place footrests on and back plate on when resident in wheelchair. OS #2 stated the evaluation determined Resident #15 required a new larger footboard to be placed behind the legs of the wheelchair to ensure the resident's legs did not touch the ground which would cause her to fall forward. OS #2 stated the new foot board was installed and education was given to staff. On 09/04/19 at 3:15 p.m., the director of nursing (DON) was asked to see the charge nurse and CNA who were on duty on 8/21/19 the day of the fall incident. The DON stated the charge nurse, was a contract nurse and her contract had recently ended, therefore she was not available. The DON stated from her understanding of the fall incident, the CNA was transporting the resident from the dining room back to her room and the resident's feet dropped down on the carpet and halted the chair causing the resident to fall out of the wheelchair. The DON was asked if there were footrests and/or a foot board/plate on the wheelchair at the time of the transport and DON stated she did not believe there was. On 09/04/19 at 3:17 p.m., the certified nursing assistant (CNA #3) who witnessed the fall incident was interviewed. CNA #3 stated she was taking Resident #15 to her room after dinner to get ready for bed. CNA #3 stated I asked her to hold her feet up and while we were going down the hall she placed her feet on the floor and this stopped the wheelchair causing her (Resident #15) to fall forward out of the chair onto the floor. CNA #3 was asked if there was supposed to be footrests and/or a foot board/plate on the wheelchair. CNA #3 stated yes, but I don't know why they weren't on there at the time. CNA #3 stated I received report from the first shift CNA and I don't think the footrests and foot board were on the wheelchair at the time I received report. CNA #3 was asked if she knew the foot rests and foot board/plate were supposed to be on the wheelchair why did she not place them prior to transporting Resident #15. CNA #3 stated you're right, it's everyone's responsibility. I should have put them on, but I don't know why they weren't on. It will probably get me in trouble. The above findings were reviewed with the administrator, director of nursing and social services director during a meeting on 09/04/19 at 4:30 p.m. On 09/05/19 at 8:30 a.m., the administrator and director of nursing were advised of the concern of harm for Resident #15 related to the fall incident which took place on 08/21/19 resulting in a fractured right clavicle. On 09/05/19 at 8:35 a.m., the occupational therapist (OS #3) who completed the OT evaluation was interviewed. OS #3 stated when she received the referral she was told it was because the resident had fallen out of the wheelchair because the staff did not have the footrests and foot board/plate on the wheelchair at the time of the incident. OS #3 stated when she assessed Resident #15 she determined a larger, wider foot board would be better because Resident #15 leans forward and slides down in the wheelchair. OS #3 stated the larger, wider foot board would prevent the resident's feet from dropping down on the floor. OS #3 was asked if Resident #15 was able to propel or assist with any of locomotion and transfers. OS #3 stated no she requires total assistance. A review of the OT evaluation form documented the following: Patient is a total assist with all ADLs (activities of living) and functional mobility. On 09/05/19 at 8:40 a.m., CNA #5 who routinely provides care during first shift was interviewed. CNA #5 stated Resident #15 does require the footrests and foot board. CNA #5 stated Resident #15 is gotten up by the third shift staff and dressed for the day. CNA #5 stated because Resident #15 stays up in the wheelchair for so long during the day, that she usually lays her down after lunch at which time the footrests and foot board are removed for a safe transfer from the chair to the bed. CNA #5 stated someone on second shift would have gotten Resident #15 up for dinner at which time they should have installed the footrests and foot board to transport her to and from the dining room for dinner. No additional information was provided to the survey team prior to the exit conference on 09/05/19 at 10:30 a.m. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses that included hospice care, chronic kidney disease - stage 3, hyperlipidemia, vascular dementia, dysphasia, chronic pain, depression, edema and gastro-esophageal reflux disease (GERD). The minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #37 as severally impaired for daily decision making with a score of 5 out of 15. Section G - Functional Status assessed Resident #37 total dependence, with two person physical assistance for transfers and total dependence with one person physical assistance for locomotion, dressing, toileting, hygiene. On 09/04/19 at 8:00 a.m., Resident #37 was observed being transported to the second unit dining room in a Broda specialized chair. On 09/04/19 at 9:45 a.m., the certified nursing assistant (CNA #4) who routinely provides care for Resident #37 was interviewed about the use of the Broda chair. CNA #4 stated the resident used the Broda chair whenever she was out of bed. Resident #37's clinical record was reviewed on 09/04/19 at 10:17 a.m.,. Observed documented in the nurses' notes was the following: 08/20/19 13:58 At 1PM while sitting in the dining room waiting to be taken back to her room resident fell out of her Broda chair face first. She was attempting to get up out of her chair unsafely. When writer came into dining room resident was lying in her right side of the floor next to chair. Writer and supervisor assessed resident, ROM was performed and resident stated that she had pain in her neck and the back of her head. She also stated that her shoulder and coccyx area were hurting as well. There was strong grip in both hands and PEARL. Vital signs were obtained and within normal limits. On call [Name of Nurse Practitioner] was notified and informed of fall and resident stating she has having pain in her neck, back of head, shoulder and coccyx area. She gave verbal order to send resident to ER for further evaluation. Daughter [name] was notified at 1:24PM and stated she would meet her mother at the hospital. Writer called in report to [name of ER nurse]. 08/20/19 16:26 Weekly Standards of Care meeting held with IDT team present to discuss fall without injury. Intervention added to Use Broda Chair until therapy evals. Continue current POC. A review of the comprehensive care plan documented the Broda chair as an intervention on the Falls care plan dated 07/25/19. The clinical record did not document physician orders for the use of Broda chair. On 09/04/19 at 1:30 p.m., the MDS coordinator (RN #1) who documented the 08/20/19 Weekly Standards of Care note was interviewed about the PT/OT evaluation for the Broda chair. RN #1 stated the referral was made because of concerns with positioning after Resident #37 had the fall from the Broda chair. RN #1 stated she was not sure if an initial evaluation was made by PT/OT when Resident #37 was admitted . On 09/04/19 at 1:47 p.m., the Rehab Manager (OS #2) was interviewed regarding an evaluation for the Broda chair. OS #2 stated the in-house therapy did not complete the evaluation because hospice wanted to have their own independent PT/OT come in and complete the evaluation. On 09/04/19 at 3:30 p.m. the director of nursing (DON) was asked if an order was needed for a Broda chair. The DON stated the resident had been admitted with the chair on the day of admission. She was asked again if the Broda chair required an a physician's order and she stated she would have to check into this since Resident #37 was admitted on Hospice and the Broda chair came with her. The DON was asked if there had been a therapy evaluation for the Broda chair. The DON stated No, we have had conversations with Hospice about having an evaluation completed, however hospice did not want to use our in-house therapy department and stated they would provide their own independent therapy evaluation. The DON was asked if she could provide documentation regarding the conversations with hospice related to the therapy evaluation for the Broda chair. The DON stated the Social Services Director should have more information regarding Resident #37 because she was receiving hospice services. On 09/04/19 at 3:45 p.m., the social services director (LPN #4) was interviewed regarding if the had been a therapy evaluation completion on the Broda chair. She stated she was not sure if there had been an initial evaluation completed at admission. LPN #4 stated she would contact hospice and provide the information. 09/04/19 at 4:15 p.m., LPN #4 provided a fax cover sheet from the [Hospice Provider] which documented the resident was admitted to the facility with the Broda chair on 07/08/19. Additional information provided were copies of physical therapy notes which documented the initial PT evaluation for the Broda chair did not take place until 08/25/19. The PT evaluation documented the following: PT services necessary to help identify and establish proper positioning of patient in Broda chair, as it is unclear if she is being positioned incorrectly or if she was attempting self-mobility which led to her fall . These findings were reviewed with the administrator, director of nursing and social services director during a meeting on 09/04/19 at 4:30 p.m. No additional information was provided prior to the exit conference on 09/05/19 at 10:30 a.m.