**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure Residents were free from significant medication errors for four Residents (Resident #40, #24, #178, and #62) in a survey sample of 41 Residents, which resulted in harm for Resident #40. The findings included: 1. For Resident #40, the facility staff failed to follow physician orders and provide an anticonvulsant (seizure medication) as ordered, which resulted in Resident #40 having a seizure and being sent to the hospital, this constituted harm. On 10/12/21 at 2:10 PM, the family member/Resident Representative of Resident #40 met with the survey team. She shared concern that Resident #40 had been hospitalized and during the course of her hospital stay had seizures. Resident #40 was started on seizure medication, Keppra while in the hospital. She stated that upon Resident #40's return to the facility the facility staff failed to administer this medication. Resident #40 had another seizure and had to be sent to the hospital. On 10/13/21 and 10/14/21, a review of the EHR (electronic health record) for Resident #40 was conducted. This review revealed that on 8/7/21, Resident #40 was hospitalized and returned to the facility on 8/16/21. Review of the EHR further revealed that hospital records from the hospitalization were in the record. Included in the hospital documents was a neurology consult dated 8/13/21, that read, While undergoing a investigations, yesterday evening, she had brief generalized tonicclonic seizure with loss of consciousness lasted less than 2 min Patient had mild facial droop. She had a CT scan of brain which was reported unremarkable. She does not have fever or new focal neurological deficit she is back to her baseline. She was started on levetiracetam and doing very well. We are unable to do MRI brain due to Permanent pacemaker. A hospital note dated 8/14/21 and 8/15/21, titled General Progress Note, both read On 8/12/21, patient with new onset seizure activity; CT evaluation negative for etiology. Cannot get MRI due to PPM [permanent pacemaker]. Additional notes in this same document read, She had a brief generalized seizure on 08/12 in the absence of a seizure history. There was noticeable left arm weakness subsequently and a stroke alert was called. There was no CT evidence of bleeding or infarction, and CTA did not reveal evidence of a flow limiting lesion. Neuro interventionalist did not feel that further investigation or treatment was warranted at this time. Local neurology consultation was recommended related to the new onset seizure. She had a 2nd brief seizure after arrival to the ICU but none since. She has been loaded with Keppra and will continue that b.i.d. [twice daily] Unable to get MRI due to pacemaker Keppra 500mg BID, check Keppra level on 8/16, seizure precautions. The hospital Discharge summary dated [DATE], noted diagnosis to include: active problem seizure. This discharge summary went on to note: take these medications: levETIRAcetam 100 MG/ML solution 500 mg, Oral, 2 times daily, commonly known as: KEPPRA. Hospital course .Seizure She had a brief generalized seizure on 08/12 in the absence of a seizure history. There was noticeable left arm weakness subsequently and a stroke alert was called. There was no CT evidence of bleeding or infarction, and CTA did not reveal evidence of a flow limiting lesion. Neuro interventionalist did not feel that further investigation or treatment was warranted at this time. Local neurology consultation was recommended related to the new onset seizure. She had a 2nd brief seizure after arrival to the ICU but none since. She has been loaded with Keppra and will continue that b.i.d. Unable to get MRI due to pacemaker. Review of Resident #40's physician orders and MAR (medication administration record) for August and September 2021, revealed that she was not ordered or administered Keppra until 9/6/21. There were multiple notes from the providers (doctor and nurse practitioner) of seeing Resident #40 from 8/16/21-9/6/21, and none of the notes made reference to the seizure activity she had in the hospital or the orders for Keppra. On 9/5/21 at 3 PM, there was a nursing note entry that read, Resident's daughter noted to be in the hallway yelling for help. This Nurse, other Nurse and Aide arrived at Resident's room where Resident's daughter stated that Resident had a seizure. Upon assessment of Resident she was noted to be unresponsive to verbal stimulation and slightly responsive to painful stimuli, with her eyes open; VS [vital signs] 112/58 [blood pressure reading], 69 [pulse], 20 [respirations], O2 88% [oxygen saturation] on 2 LPM [2 liters of oxygen per minute]. Resident was unresponsive for 3 minutes. No further seizure like activity noted. On call [Nurse Practitioner name redacted] made aware and gave N.O. [new order] Send Resident to ER [emergency room] for eval [evaluation] and tx [treatment]. Resident and RP [responsible person] made aware. On 9/8/21, there was a progress note written by the nurse practitioner that read, Upon review of previous d/c [discharge] summary, it appears pt [patient] possibly had seizure like activity at that time and was discharged with recommendation for keppra, which was somehow overlooked. On 10/13/21, the Director of Nursing provided a document dated 9/6/21, titled Medication Error that read, Upon admission on [DATE] Keppra order not transcribed to EMAR (electronic medication administration record). Also provided was a copy of an IDT (interdisciplinary team) Meeting Progress Note dated 9/10/21, that read, Resident readmitted to facility and Keppra omitted from active meds. On 10/14/21 at 2:10 PM, a telephone interview was conducted with Employee F, the Nurse Practitioner. Employee F was asked if she would ever not agree to an order from the hospital for a Resident to be on Keppra. Employee F stated, No, we absolutely would order that. Employee F was asked about the details of Resident #40 not receiving Keppra as ordered by the hospital following her having 2 seizures while in ICU (intensive care unit) at the hospital. Employee F stated, It could have been prevented, I do carry some fault in that. All of it could have been avoided. On 10/14/21 at approximately 3:50 PM, an interview was conducted with LPN C, who was the admitting nurse when Resident #40 returned to the facility on 8/16/21. LPN C stated she had received report from the hospital as well as discharge paperwork. She assessed Resident #40 then called the NP (nurse practitioner) and reviewed the hospital records and orders. LPN C stated she told the NP of the seizure activity in the hospital and was advised to leave it as is and she [the NP] would review them when she came in the next day. LPN C very emotionally said I would never hurt her, I'm so sorry [referring to Resident #40]. On 10/14/21 at 4:31 PM, the facility Administrator stated their contracted medical provider for physician services has a phone system that tracks phone calls. She then provided an email that indicated the medical provider received a call from the facility staff on 8/16/21 at 1:51 PM. On 10/15/21, the Administrator returned to the conference room and had obtained the recording of the conversation between facility staff and the medical provider regarding Resident #40's readmission to the facility. Surveyors D & F listened to the conversation which was between LPN C and Employee F. During this call Employee F, the nurse practitioner stated, go ahead and start whatever their changes are [the hospital orders], that's fine. I'll look at them tomorrow when I'm in there, we will request their [the hospital] records. Obviously they would have had neurology [evaluation] and I'm curious what they think happened. On 10/15/21 at 11:30 AM, a telephone interview was conducted with Other Staff B, the pharmacist. Other Staff B stated, Keppra is a central nervous system anticonvulsant, the side effects would be allergy or adverse reaction history or excessive sedation, which can be controlled by dose adjustments. If someone has had a seizure I don't know why it wouldn't be given unless they were on another medication for this and it would be duplicate therapy. On 10/15/21 at 9:44 AM, an interview was conducted with the Director of Nursing. She was asked what constitutes a medication error, she stated, If a medication is not available, given in error or isn't given. The facility policy titled Medication Related Errors read, 4. Administration Errors: In the event of an administration error, facility staff should follow facility policy relating to the medication administration errors .4.9 Omission Error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication. On 10/15/21, the facility Administrator was notified of Resident #40 not receiving her seizure medication, which resulted in a seizure and hospital visit constituting harm. No further information was provided. 2. For Resident #24 the facility staff failed to administer an anticoagulant (blood thinner) for 3 of 4 doses scheduled in a 48 hour time frame, this is a significant medication error. On 10/13/21-10/14/21, a review of Resident #24's EHR (electronic health record) was conducted. Resident #24 was noted to have a diagnosis of paroxysmal atrial fibrillation. Physician orders revealed an order dated 8/9/21, that read, Brilinta Tablet 90 MG (Ticagrelor) Give 1 tablet by mouth two times a day for Blood thinner. This order was still active. Review of Resident #24's MAR for October revealed that on 10/4 the 8:30 AM dose was not given and had a code 19 in the block. On 10/5/21, neither of the 2 scheduled doses were administered and both had a code 19 in the block. The last page of the MAR had a legend that indicated, 19=Other / See Nurse Notes. Review of the nursing notes for these 2 days read, Brilinta Tablet 90 MG, Give 1 tablet by mouth two times a day for Blood thinner unavailable, Brilinta Tablet 90 MG, Give 1 tablet by mouth two times a day for Blood thinner not in cart, and Brilinta Tablet 90 MG, Give 1 tablet by mouth two times a day for Blood thinner on order. On 10/13/21, RN D was asked to verify that Resident #24's medication Brilinta was available. At the medication cart RN D was able to verify that Brilinta was currently in stock. She was asked about the notes on 10/4 & 10/5, and why the medication was not given, and she said it says it wasn't available. RN D confirmed that the process is that the staff would order medications several days before running out to ensure the pharmacy had time to deliver a refill. On 10/14/21 at 1:37 PM, an interview was conducted with the DON (Director of Nursing). The DON stated, if meds (medications) are not available staff are to try to get them out of the Omnicell (in-house stock of medications), if they can't they are to call the pharmacy and physician. The DON confirmed the process for reordering medications, which she said, there are several options, you can press the reorder button in the computer or call the pharmacy. When asked when meds are to be ordered, the DON said, when meds get down to a 7 day supply we will go ahead and order them to prevent them from running out. The DON stated the risks of not receiving blood thinners as ordered is, they run the risk of getting a blood clot, which could cause the loss of limb or life. She confirmed this is an important medication to receive. On 10/14/21 at 2:10 PM, a telephone interview was conducted with Employee F, the Nurse Practitioner. Employee F was asked about the medication Brilinta and its use. Employee F stated, it is an anticoagulant usually given when people have heart failure, it is a last ditch effort. When asked the risks if someone doesn't get this as ordered, Employee F stated, it depends on the circumstances, 1 dose is not terrible but missing multiple doses could put them at risk for heart failure or create clots. Employee F was made aware that Resident #24 had missed 3 of 4 scheduled doses in a 48 hour period. Employee F stated she was not aware of this. On 10/15/21 at 11:30 AM, a telephone interview was conducted with Other Staff B, the pharmacist. Other Staff B stated, Brilinta is an antiplatelet medication, the reason someone takes it is to prevent a thromboembolism (blood clot) or MI (myocardial infarction/heart attack). Missed doses would result in higher risks for these things. Other Staff B stated, the pharmacy makes 2 deliveries to the facility daily and also has a local retail pharmacy that can be used for back-up if medications are not available and are not in the Omnicell [emergency box of medications maintained on-site]. When asked about cut off times, she stated, if a medication is ordered before 11:30 PM, we have it on the delivery that comes that night, same for the day delivery, as long as we get it [the order/refill request] about an hour to 30 minutes before we leave the pharmacy with the delivery, it can be included in that delivery. The facility policy titled Medication Related Errors read, 4. Administration Errors: In the event of an administration error, facility staff should follow facility policy relating to the medication administration errors .4.9 Omission Error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication. On 10/14/21, the facility Administrator and DON were made aware of the findings. No further information was received. 4. For Resident #62, the facility staff failed to administer Lantus (Insulin Glargine) on 10/04/2021 and 10/05/2021 as ordered by the physician. Also, Novolog (Insulin Aspart) was not signed off as administered on 10/06/2021 at 0800 (8:00 A.M.) and 1700 (5:00 P.M.) On 10/25/2021 at approximately 9:45 A.M., Resident #62's clinical record was reviewed. A physician's order dated 08/02/2021 documented, Lantus Solution 100 unit/ml [milliliters] (Insulin Glargine) Inject 65 unit subcutaneously at bedtime for DMII [diabetes mellitus type 2]. A physician's order dated 08/05/2021 documented, Novolog (Insulin Aspart) 100 unit/ml [milliliters] Inject per sliding scale . A physician's order dated 08/20/2021 documented Novolog (Insulin Aspart) 100 unit/ml. Inject 5 unit subcutaneously with meals for DMII in addition to sliding scale. The Medication Administration Record (MAR) for October 2021 was reviewed. Pertaining to Lantus (Insulin Glargine) Inject 65 units subcutaneously at bedtime: The Lantus was signed off as administered at bedtime with the exception of 10/04/2021 and 10/05/2021. For 10/04/2021 and 10/05/2021, the administration Insulin Glargine (65 units) at 2100 [9:00 P.M.] was coded as 3 meaning no insulin required (according to the MAR legend). The BS [blood sugar] value on 10/04/2021 at 2100 was documented as 183. The BS [blood sugar] value on 10/05/2021 at 2100 was documented as 125. Pertaining to Novolog (Insulin Aspart) Inject 5 unit subcutaneously with meals for DMII in addition to sliding scale: The Novolog was signed off as administered with the exception of 10/06/2021 at 0800 [8:00 A.M.] which was coded as 19 meaning other/see nurses notes (according to the MAR legend) and 10/06/2021 at 1700 [5:00 P.M.] which was blank. A nurse's note dated 10/06/2021 at 11:23 A.M. documented that the Novolog was on order. There was no nurse's note addressing why Novolog was not signed off as administered on 10/06/2021 at 1700. On 10/25/2021 at 11:50 A.M., an interview with Licensed Practical Nurse D (LPN D) was conducted. When asked about the process if insulin is unavailable for administration, LPN D stated they have an emergency supply of insulin in the refrigerator. LPN D stated they would use the emergency supply and also notify the pharmacy. This surveyor and LPN D then went to observe the ekit contents for insulin which did contain several types of insulin vials and pens including Lantus and Novolog. On 10/25/2021 at 1:00 P.M., the Director of Nursing (DON) was notified of findings and the DON indicated she would look into it. At 2:20 P.M., the DON stated that it was an agency nurse that documented no insulin required for the Lantus on 10/04/2021 and 10/05/2021. The DON also stated that I can't speak for her but it looked like she was addressing the sliding scale [where no insulin was required for blood sugar values less than 200] and applied it to the Lantus. Pertaining to the nurse's note indicating Novolog was on order and not administered, the DON stated that staff are expected to use the extra insulin supply on hand and doesn't know why it wasn't administered. On 10/25/2021 at approximately 3:30 P.M., the administrator was notified of findings. The administrator and DON stated there was no further information or documentation to submit. 3. For Resident #178 the facility staff failed to administer insulin, antibiotics, pain medications, medications as ordered by physician. A review of the clinical record revealed that Resident #178 was admitted to the facility on [DATE] at 8 PM, after having been hospitalized and had surgery for necrotizing fasciitis (also known as flesh eating bacteria) to her inner thigh. Among Resident # 178's discharge summary were orders for the following medications: Resident #178 had an order for Clindamycin 300 mg one capsule every six hours (an antibiotic). -A review of the MAR (Medication Administration Record) revealed that Resident #178 did not receive 5 doses of this medication - A review of the progress notes revealed that nurses documented medication was unavailable. However, a review of the stat box contents revealed this medication was available in the stat box. Resident #178 had an order for Cefepime 2 grams/100 ml IV (an antibiotic) A review of the MAR revealed that the resident did not receive seven doses of IV Cefepime 2 grams/ 100 ml between 8/12/21 and 8/15/21. Progress note on 8/14/21 at 11:50 AM read: Pharmacy contacted re: Cefepime HCl solution reconstituted 2 grams as medication not received. Per pharmacy IV department not available at this time message left for a return call. 8/14/21 at 4:11 PM IV department contacted no return call received per pharmacy IV department IV antibiotics order not received order re-faxed to the pharmacy order currently not updated in [name of pharmacy computer program redacted] to pull medication for administration. 8/15/21 at 3:59 PM Pharmacy contacted again this shift as IV abx not received. Per pharmacy medication not sent d/t allergy to Ceclor. Per discharge information, resident was receiving this medication in hospital without side effects. On-call NP made aware with approval to contact pharmacy again and update on approval to send medication. Pharmacy verbally contacted + faxed for notification of approval to continue IV abx per current orders. Resident #178 had an order for Gabapentin 600 mg 1 tablet three times a day for neuropathic pain-A review of the MAR revealed the resident missed nine doses of gabapentin. A review of the progress notes revealed the nurses documented medication unavailable awaiting from pharmacy. A review of the Stat Box contents revealed the medication was available in the stat box in a lower dose strength (300 mg) Resident #178 had an order for Insulin Glargine (Lantus) 60 units a day missed 6 doses. The facility MAR has orders that read: Insulin Glargine (Lantus) solution 100 units/ml inject 60 units subcutaneously at bedtime for DM2 (diabetes) Start Date 8/12/21 at 9:00 PM A review of the MAR reveals that it is coded as 19 (which means see nurses notes) for 8/12/21 - 8/16/21 (4 missed doses) then it was discontinued on the 16th and not restarted until 8/18/21. (2 more doses missed). A review of the Nurses notes revealed the nurses were documenting waiting for med from pharmacy. On 10/13/21 at approximately 11:25 AM an interview was conducted with the DON who was stated the Pharmacy makes two runs a day. They come in the middle of the night and in the middle of the day. When asked how long it takes to get orders in the system for a new admission she stated that it takes about 2 hours. When asked what the cutoff time to get the medications on the next run she stated it is at 11:30 PM. She further stated that Resident #178 should have had her medications in the middle of the night run. When asked if there is a backup pharmacy she stated that there was a backup pharmacy. On 10/14/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.