**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility was not free of significant medication errors for 2 residents (R) (R54 and R170) of 11 sampled residents. R54 received five extra doses of baclofen (a medication used to treat muscle spasms) on 1/15/25 and 1/16/25 due to a transcription error. R54 experienced overdose symptoms that required emergency transport and admission to the hospital on 1/17/25. R170 was administered double the ordered dose of long-acting insulin on 3/1/25 and 3/2/25. Findings include: The facility's Medication Administration policy, revised 2/6/25, indicates: .All medications shall be administered following the seven rights of administration. Right: Medication, Dose, Member, Route, Time, Documentation, Indication .Orders and administration instructions shall be followed at all times .Medication errors shall be reported immediately to the Registered Nurse (RN) . The facility's Orders Management policy, revised 5/1/24, indicates: .The RN is responsible to review the member's plan of care to address revisions needed based on prescribed orders. Orders transcribed in the electronic health record by anyone other than a nurse shall require RN review for accuracy and confirmation prior to administration. Orders from other than the Primary Care Physician (PCP)/designee shall be reviewed and verified with the PCP/designee .Order clarifications shall be documented in the clinical record. Holding orders shall require an end date or duration. Hold orders without an end date or duration shall be clarified with the provider and discontinued, requiring a new provider's order to restart. All orders shall be addressed and processed promptly unless clarification is needed; those needing clarification shall be addressed timely for processing. All transcription errors shall be promptly reported to the RN .When transcribing orders, the prescriber shall always be identified as the ordering provider . 1. On 3/17/25, Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease and chronic kidney disease. R54's Minimum Data Set (MDS) assessment, dated 1/8/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R54 had moderate cognitive impairment. R54 had a Power of Attorney for Healthcare (POAHC) who was responsible for R54's healthcare decisions. R54's medical record indicated R54 was transferred to the hospital on 1/17/25 and readmitted to the facility on [DATE]. An Order note, dated 1/14/25 at 4:59 PM, indicated baclofen 10 milligrams (mg) four times daily (QID) exceeded the usual frequency of one to three times per day. An Administration note by Licensed Practical Nurse (LPN)-F, dated 1/14/25 at 5:05 PM, indicated there was a duplicate order. A Respiratory Therapy note, dated 1/16/25 at 2:00 PM, indicated R54 was extremely drowsy during nebulizer treatments. The Respiratory Therapist reported the information to an RN. An Administration note by LPN-F, dated 1/16/25 at 8:43 PM, indicated R54 was unable to safely take a medication due to lethargy. A Notification note, dated 1/16/25 at 10:11 PM, indicated the on-call physician was notified of a medication error at 9:40 PM. The physician instructed staff to hold baclofen until R54 was alert and monitor R54 overnight. The note indicated R54's POAHC was notified of the medication error and monitoring order. An Incident note, dated 1/16/25 at 10:15 PM, indicated a new order was received on 1/14/25 to increase baclofen 10 mg from three times daily (TID) to QID; however, the TID order was not discontinued and an order to administer baclofen 10 mg QID was added. The error was found in the evening on 1/16/25. R54's vital signs were within normal limits, however, R54 exhibited increased fatigue and weakness. A note, dated 1/17/25 at 12:30 AM, indicated R54 was assessed by an RN. Adverse effects from the medication error were unknown at that time because R54 was sleeping soundly and slept through the assessment. R54's respiratory rate was even, shallow, and unlabored with no concerns. A Health Status note, dated 1/17/25 at 6:51 AM, indicated an RN was called to R54's room at approximately 5:25 AM because R54's legs were shaking. The RN observed R54 in bed and noted both lower legs were shaking with the left leg shaking more than the right. R54's arms could not extend and R54's fists were clenched. R54 was confused, answered only yes or no, and had a delayed response to questions. The on-call physician (who was already aware of the medication error) was notified and requested staff administer carbidopa/levodopa (a medication used to treat Parkinson's disease symptoms of stiff joints and movement), however, R54 was too sleepy to use a straw or swallow. The on-call physician instructed staff to send R54 to the emergency room (ER). R54 left the facility with Emergency Medical Services (EMS) at approximately 6:10 AM. The RN was unable to obtain vital signs due to R54's condition. ER physician notes, dated 1/17/25, indicated R54 was alert and had tremors of both lower legs with stiffness. R54 was sedate but responded to painful and loud verbal stimuli. R54 was conversant upon EMS' arrival at the facility but was sedate and tremulous upon arrival at the ER. The ER physician discussed the case with Poison Control and obtained additional blood levels based on Poison Control's recommendations. The levels were reassuring and R54's condition appeared to be an accidental baclofen overdose. A hospital history and physical note, dated 1/17/25, indicated there was difficulty assessing R54's neurological status at the time of admission to the hospital from the ER. R54 appeared uncomfortable. R54's eyes were open, however, R54 did not follow commands, moaned incomprehensible words, and did not answer questions. R54's arms were stiff with mild tremors. On 3/19/25 at 10:15 AM, Surveyor interviewed Medical Director (MD)-G via phone. MD-G indicated MD-G was aware of the baclofen medication error within 24 hours if not the same day. MD-G indicated the on-call physician was immediately notified when the error was discovered. MD-G indicated MD-G would have issued the same orders as the on-call physician. MD-G indicated when R54's baclofen order was increased by a specialty physician, the nurse should have entered the order in R54's medical record correctly by discontinuing the previous baclofen TID order or should have questioned the physician with any concerns. MD-G indicated the medication error led to R54's hospitalization and indicated the most severe outcomes of a baclofen overdose are mild respiratory distress, sedation, and cognitive changes. MD-G indicated the quantity of baclofen R54 received for the short period of time was not life-threatening but could cause cognitive changes. MD-G participated in the facility's improvement process to determine the cause of the error and reeducate staff in collaboration with the pharmacy. MD-G indicated R54's medical record should have triggered an alert when the order was entered because both the TID and QID orders together exceeded the standard dosing. MD-G indicated standard dosing for baclofen should not exceed 80 mg total per day. MD-G indicated the medication error put (R54) close to that. On 3/19/25 at 10:34 AM, Surveyor again interviewed MD-G via phone. MD-G indicated R54's medical record did generate an alert (see note above) and MD-G believed the pharmacy discontinued the TID order from their end. Surveyor reviewed R54's January 2025 medication administration record (MAR) which contained the following orders: ~ Baclofen 10 mg TID: ordered 9/4/24 and discontinued 1/16/25 at 8:36 PM - received all scheduled doses in January as ordered (at 6:30 AM, 10:30 AM and 6:30 PM) with the following exceptions: no signature on 1/14/25 for the 10:30 AM dose, the 1/14/25 6:30 PM dose was held, no signature on 1/16/25 for the 6:30 PM dose. ~ Baclofen 10 mg QID: ordered 1/14/25 at 3:00 PM and discontinued 1/21/25 at 11:58 AM - received all scheduled doses as ordered (6:30 AM, 10:30 AM, 2:30 PM and 6:30 PM) with the following exceptions: the 6:30 PM dose was documented as refused on 1/16/25. All doses thereafter were not administered because R54 was hospitalized . Based on the above information, R54's MAR indicated R54 received double doses of baclofen (a total of 20 mg each time) on 1/15/25 at 6:30 AM, 10:30 AM, and 6:30 PM and on 1/16/25 at 6:30 AM and 10:30 AM for a total of five double doses. On 3/19/25 at 10:49 AM, Surveyor interviewed Director of Nursing (DON)-B. Immediately after discovering the error, DON-B indicated the facility re-educated all nurses regarding the transcription process and provided one-on-one education to the RN who transcribed R54's baclofen order incorrectly. DON-B indicated LPN-F reported the duplicate order to the RN on 1/14/25 and the RN indicated the RN would take care of it but got distracted. DON-B indicated the facility conducted informal audits of orders following R54's medication error but had no documentation of the audits. DON-B indicated no medication errors had occurred since then. On 3/19/25, Surveyor reviewed the facility's investigation for the medication error which contained a Record of Conversation/Notice, dated 1/25/25, that indicated RN-H was counseled regarding failure to discontinue a duplicate order for a medication which resulted in a medication overdose and hospitalization. The investigation did not indicate a process change was implemented to prevent additional errors and did not contain audits to determine if any other residents were affected. On 3/19/25 at 1:51 PM, Surveyor interviewed DON-B who indicated the process change implemented in response to the medication error is to have staff enter the ordering physician's name with the order unless the PCP is the ordering provider. DON-B verified the process change did not really fix the root cause of the medication error. DON-B indicated the education provided to staff was on the process change plus the overall transcription process. 2. From 3/17/25 to 3/19/25, Surveyor reviewed R170's medical record. R170 was admitted to the facility on [DATE] and had diagnosis of type 2 diabetes mellitus. R170's most recent MDS assessment, dated 2/3/25, indicated R170 had moderate cognitive impairment. On 3/17/25 at 10:21 AM, Surveyor interviewed R170 who indicated R170 had unpredictable fluctuations in R170's blood glucose levels since admission to the facility. On 3/19/25, Surveyor reviewed R170's MAR which included the following long-acting insulin orders: ~ Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/milliliter (ml) (insulin glargine) Inject 14 units subcutaneously at bedtime for diabetes type 2. When pen is completed, please refer to Semglee order. Have RN initiate Semglee order and discontinue Lantus (ordered and started 1/27/25; discontinued 2/7/25). ~ Semglee Subcutaneous Solution Pen-injector 100 units/ml (insulin glargine-yfgn) Inject 14 units subcutaneously at bedtime for diabetes type 2 (ordered 1/27/25; started 1/29/25; discontinued 3/3/25). ~ Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/ml (insulin glargine) Inject 12 units subcutaneously at bedtime for diabetes type 2. When pen is completed, please refer to Semglee order. Have RN initiate Semglee order and discontinue Lantus (ordered and started 2/7/25 for indefinite). R170's medical record indicated R170 was to transition from Lantus SoloStar to Semglee when R170's home supply of Lantus SoloStar was exhausted. The order for Semglee was entered and held from 1/27/25 to 1/29/25. On 3/1/25, Semglee was started but Lantus SoloStar was not discontinued. On 3/1/25 at 6:30 PM, R170 received 14 units of Semglee (insulin glargine-yfgn) and 12 units of Lantus (insulin glargine). On 3/2/25 at 2:30 AM, R170 had an episode of asymptomatic hypoglycemia (low blood sugar). R170's continuous glucose monitoring device alarmed for a blood glucose of 78. On 3/2/25 at 6:30 PM, R170 received 14 units of Semglee (insulin glargine-yfgn) and 12 units of Lantus (insulin glargine). On 3/3/25 at 4:36 AM, R170 had an episode of asymptomatic hypoglycemia. R170's continuous glucose monitoring device alarmed for a blood glucose of 78. On 3/19/25 at 1:54 PM, Surveyor interviewed DON-B who indicated there was not an investigation for the insulin error and staff were not interviewed following the error. DON-B indicated staff education was not completed and a process change(s) was not implemented to prevent similar medication errors.