Every finding on record at Brown Health and Rehabilitation

Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition, the facility failed to protect residents from sexual abuse by another resident by not reporting to the State Survey Agency (SSA) within the required timeframe for one resident (R) (R85) reviewed for abuse and neglect. The deficient practice had the potential of future unreported abuse.Findings include:Review of the facility policy titled Abuse Prohibition review date 4/7/2025 revealed under Policy: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is withing our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and, or their property. The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse. Under Identification of coverage and responsibility: Any person observing abuse, neglect, or exploitation as previously defined, should immediately report it to the Administrator or the direct supervisor (i.e. Charge Nurse, Director of Nursing, Departmental Leaders) present at the time of the incident.Review of the Five-Day follow-up dated 4/28/2025 summarized the details of the incident:Certified Medication Aide (CMA) JJ approached Administrator during a resident care meeting and states she observed male resident inappropriately touch R85 several months ago. CMA JJ stated she doesn't remember exactly when, but she told the nurse who said they would report. CMA JJ could not remember who she told about incident. She heard R85 giggling and turned to see male resident reaching across and grabbing R85's breast. CMA JJ told male resident to stop immediately and moved R85 away. Further review revealed that CMA JJ received 1:1 (one to one) education regarding immediately reporting to the Administrator as Abuse Coordinator.Interview with the Administrator on 9/11/2025 at 10:00 am revealed that CMA JJ was no longer employed by the facility. The incident took place before the current Administrator accepted their position. The Administrator confirmed that staff received regular in-services related to abuse and abuse reporting.

Based on observations, staff interviews and review of the facility's policy titled, Infection Prevention Plan, the facility failed to ensure proper infection control procedures were followed for four residents (R) (R5, R11, R1 and R78), creating cross-contamination. This failure had the potential to contribute to the transmission of infectious diseases among residents and staff. Findings include:Review of the facility's policy titled, Infection Prevention Plan, dated 12/27/2024 revealed, under Scope Prevention of Infections - Policies, procedures, and aseptic practices are followed by personnel when performing procedures and disinfecting equipment.Observation on 9/10/2025 at 8:25 am, Certified Medication Aide (CMA) AA was performing a medication pass for R5 in Dining Room Three. CMA AA was observed with a paper towel placed on the medication cart as a barrier. She proceeded to administer medications to R11 and then R1 without changing the barrier, creating cross contamination. Interview on 9/10/25 at 9:00am with CMA AA, confirmed she used a barrier on her medication cart and did not change it between residents. CMA AA confirmed it should have been changed between residents. Observation and subsequent interview on 9/10/25 at 8:44 am revealed CMA BB administering medications to R78 with a paper towel taped to the medication cart surface as a barrier. CMA BB completed the medication pass for R78 and proceeded to the next room without changing the barrier, creating cross contamination. CMA BB confirmed the barrier was not changed between residents. Interview on 9/10/2025 at 9:26 am with the Director of Nursing (DON) confirmed the nursing staff were expected to change barriers between residents during medication administration to prevent cross contamination.

Based on observation, interview, record review, and review of the facility's policy titled, Standard Patient Room Cleaning, the facility failed to ensure prevention of spread of infection by using foam protectors in disrepair over bed rails that created an uncleanable surface for four of four Residents (R) (R19, R22, R10, and R13) reviewed for side rail use. This deficient practice had the potential for the foam covers on the side rails to harbor bacteria and spread infection to the residents. Findings include: Review of the facility's policy titled, Standard Patient Room Cleaning, dated January 2024, revealed 5. DISINFECT: . b. Patient zone: Using the same microfiber cloth and enhanced disinfectant, clean and disinfect surfaces in the patient's zone (i.e., over bed table, bed rails, bedside table, phone, call light cord). 1. Review of R22's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R22 was admitted with diagnoses including rheumatoid arthritis and chronic pain syndrome. Review of the Care Plan tab in R22's EMR revealed an intervention initiated 7/14/2023 to apply side rails to the bed. The Care Plan lacked documentation of reason indicating a need to pad the side rails. During an observation on 4/2/2024 at 1:56 pm in R22's room, bilateral 1/4 side rails attached to the upper frame of the resident's bed were covered with a gray foam padding and secured with duct tape. During an interview on 4/3/2024 at 3:31 pm, the Director of Nursing (DON) expressed a lack of understanding of the concern for the uncleanable surface of the foam on the side rails, stating it was just their germs. During an observation on 4/4/2024 at 2:19 pm, the foam padding on the R22's bed rails was cracked and peeling, exposing porous areas of the foam. During an interview on 4/4/2024 at 11:21 am, in R22's room, R22 verbalized they did not know the reason for the foam padding on the rails on the bed and the foam had been in place since the admission in June 2023. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director explained a work request was placed in the TELS (building maintenance documentation system) system to pad the resident's bed rails. He acquired the foam from Ace Hardware (same foam used to apply insulation to the outside of pipes), cut it to size, and secured it with tape to the bed rails. During an interview on 4/5/2024 at 11:10 am, the Infection Preventionist (IP) confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam. 2. Review of R19's Face Sheet, located in the EMR under the Face Sheet tab, revealed R19 was admitted with diagnoses including Alzheimer's disease and unspecified lack of coordination. Review of the Care Plan tab in R19's EMR revealed an intervention initiated 2/5/2023 to apply side rails to the bed. The Care Plan lacked documentation of reason indicating a need to pad the side rails. During an observation on 4/2/2024 at 1:56 pm in R19's room, bilateral side rails attached to the upper frame of the resident's bed were covered with a gray foam and secured with black tape. During an observation on 4/4/2024 at 2:19 pm, the foam padding on R19's bed rails was cracked, pitted, and part peeled off exposing porous areas of foam. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director explained a work request was placed in the TELS system to pad the resident's bed rails. He acquired the foam from Ace Hardware (same foam used to apply insulation to the outside of pipes), cut it to size, and secured it with tape to the bed rails. During an interview on 4/5/2024 at 11:10 am, the IP confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam. 3. Review of R10's undated Face Sheet located in the EMR under the Face Sheet tab revealed R10 was admitted with diagnoses of amnesia and difficulty walking. Review of R10's Care Plan, revised 4/4/2024, located in the EMR under the Care Plan tab, indicated a problem of Skin breakdown: at risk for/actual and an intervention to Continue padded rails related to history of bruising. Observations in R10's room on 4/2/2024 at 9:36 am and 4/4/2024 at 9:22 am revealed R10 lying in bed with two side rails elevated at the top of the bed with gray foam covering the top of the side rail, secured with gray tape. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director revealed the nurses submitted a work order for the foam padding for the side rails, which he ordered and picked up from (Name of Store) Hardware, then secured it to the side rails with duct tape. During an interview on 4/5/2024 at 11:10 am, the IP confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam. 4. Review of R12's undated Face Sheet, located in the EMR under the Face Sheet tab, revealed R12 was admitted with diagnoses that included dementia and transient cerebral ischemic attack (stroke). Review of R12's Care Plan, revised 4/4/2024 and located in the EMR under the Care Plan tab, revealed a problem of Skin breakdown: at risk for/actual and an intervention to Continue padded side rail on left per patient preference. Observations in R12's room on 4/2/2024 at 11:35 am and 4/3/2024 at 8:39 am revealed R12 was lying in bed with two side rails raised at the top of the bed with a dark gray foam covering the top of the left side rail, secured with black tape at the top and bottom of the rail. During an interview on 4/3/2024 at 8:39 am, R12 stated she did not know when or why the foam was applied to the side rail. During an interview on 4/4/2024 at 12:30 pm, Registered Nurse (RN) 1 stated the foam was applied to the bed rails to prevent skin tears or bruises on the resident's arms due to her fragile skin. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director revealed the nurses submitted a work order for the foam padding for the side rails which he ordered and picked up from (Name of Store) Hardware, then secured it to the side rails with duct tape. During an interview on 4/5/2024 at 11:10 am, the IP confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam. 39540

Based on interviews, record review, and review of the facility's policy titled, Abuse Prohibition--Reporting and Investigating, the facility failed to complete a thorough investigation for two of two sampled Residents (R) (R48 and R82) reviewed for abuse. Specifically, there was no evidence the facility interviewed R48 the victim, other staff, or residents regarding the allegations of potential sexual abuse as a part of the facility's investigations. Findings include: Review of the facility's policy titled, Abuse Prohibition--Reporting and Investigating dated 12/29/2023 under the section titled, Guidelines indicated . Interviews will be conducted of pertinent parties. Written signed statements from any involved parties will be obtained if possible or a witnessed, signed interview would be an appropriate alternative. Information regarding the event will be gathered from the suspect, person making the accusations, patient involved, reliable patients who may have witnessed the incident, and any other persons who may have witnessed the incident, and any other persons who may have credible, pertinent information . All investigative information will be kept on file in a secured location. All information gathered is confidential in nature . Review of an undated document provided by the facility titled, Face Sheet indicated R82 was admitted with a diagnosis of dementia. Review of a document provided by the facility titled, Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/26/2024, indicated R82 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severely impaired cognition. The assessment indicated the resident wandered and was ambulatory. Review of a document provided by the facility titled Face Sheet indicated R48 was admitted with a diagnosis of Parkinson's disease. Review of a document provided by the facility titled, Admission MDS, with an ARD of 1/25/2024, indicated R48 had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident had no behaviors such as hallucinations or delusions. The assessment indicated the resident used a wheelchair and required substantial to maximum assistance from staff for activities of daily living. Review of a file provided by the facility (referred to as the facility's investigation of a 3/6/2024 incident), dated 3/14/2024, indicated R82 was observed to kiss R48 on the cheek. To determine consent and competency of R48, the facility completed another BIMS and the resident scored a six out of 15, which revealed severe cognitive impairment. Both R48 and R82 were separated. According to the facility's investigation, R82 attempted to enter the room of R48 and was redirected. The investigation indicated R48 was transferred to the opposite side of the building. The facility could not substantiate abuse. There was no evidence the facility interviewed other staff regarding the allegations of potential sexual abuse. In addition, there was no evidence R48, the victim, was interviewed as part of the facility's investigation. Review of a file provided by the facility (referred to as the facility's investigation of a 3/18/2024 incident) dated 3/26/2024 indicated a staff member was attending to R48, while she was in a wheelchair and out in the hallway. The investigation revealed R82 leaned over R48 and kissed her cheek. Staff immediately removed R82 from R48. According to the facility's investigation, R82 was upset he could not pursue a relationship with R48. R82 was sent to a local hospital for a psychiatric evaluation and returned back to the facility three days later. Facility-wide training with staff occurred and the facility implemented 15-minute checks for R82. The investigation revealed R48 was to be monitored by the staff. The facility could not substantiate abuse. There was no evidence the facility interviewed other staff regarding this allegation of potential sexual abuse. In addition, there was no evidence R48, the victim, was interviewed as part of the facility's investigations. The facility also failed to ensure residents were interviewed as part of the facility's investigation. Review of R82's and R48's clinical records revealed there were no staff witness statements documented for the incidents dated 3/6/2024 and on 3/18/2024. During an interview on 4/2/2024 at 5:29 pm, the Administrator stated she did not collect a statement from R48 since the resident had a low Brief Interview for Mental Status (BIMS) score. The Administrator stated the staff who witnessed the two incidents between R48 and R82, were in the clinical records.

Based on interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete and electronically transmit a Discharge Minimum Data Set (MDS) assessment to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two of two residents (R) (R35 and R80) reviewed for discharge to home. Findings include: Review of the RAI Manual, dated 10/1/2019, indicated, There are three types of discharges: two are OBRA [Omnibus Budget Reconciliation Act] required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS [Prospective Payment System] Discharge. A Discharge assessment is required with all three types of discharges . Any of the following situations warrant a Discharge assessment . Resident is discharged from the facility to a private residence . Discharge Assessment - return not anticipated. 1. Review of an undated document provided by the facility titled, Face Sheet indicated R35 was admitted to the facility on [DATE] and was discharged home on 12/21/2023. Review of a document provided by the facility titled, Nursing Home Part A PPS Discharge MDS with an assessment reference date (ARD) of 12/20/2023, indicated R35 ended Medicare skilled nursing care. There was no evidence of a discharge assessment completed which would indicate R35 was discharged from the facility to home and would not return to the facility. 2. Review of an undated document provided by the facility titled, Face Sheet indicated R80 was admitted to the facility on [DATE] and was discharged home on 11/27/2023. Review of a document provided by the facility titled, Nursing Home Part A PPS Discharge MDS, with an ARD of 11/26/2023, indicated R80 ended Medicare skilled nursing care. There was no evidence of a discharge assessment completed which would indicate R80 was discharged to home and would not return to the facility. During an interview on 4/3/2024 at 2:55 pm, the MDS Coordinator confirmed R35 and R80 should have had an OBRA discharge MDS assessment to indicate the two residents were discharged and not returning to the facility. During an interview on 4/4/2024 at 8:53 am, the Administrator and Director of Nursing stated it was their expectation that all mandatory MDS assessments be completed and transmitted per RAI requirements.

Based on interviews, record review, and review of facility's policy titled, Patient's Plan of Care, the facility failed to update a Care Plan for one Resident (R) (R31) when a pacemaker monitoring device was provided to the facility and failed to ensure one (R1) was invited to participate in the quarterly care plan meeting. These failures had the potential for R31 not to receive necessary care and services for a pacemaker monitoring device and R1 not to be involved in decisions affecting care in the facility. The sample size was 41 residents. Findings include: Review of the facility policy titled, Patient's Plan of Care, dated 12/29/2023, revealed The patient's care plan should be reviewed . and revised based on changing goals, preferences, and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. The policy also documented, The center will provide the patient and/or patient's representative with advance notice of care planning conferences to enable patient/patient representative participation at a time the patient/patient representative is available to participate, in person or via phone call/video conferencing . 1. Review of R31's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet' tab, revealed R31 was admitted with diagnoses including sick sinus syndrome, left bundle branch block, and presence of a cardiac pacemaker. Review of R31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/2024 and located in the MDS tab of the EMR, revealed a Brief Interview of Mental Status (BIMS) score of 99, which indicated severe cognitive impairment. R31's diagnoses included heart failure and hypertension. Review of the Care Plan tab in the EMR under the focus area for anticoagulant related to left bundle branch block, sick sinus syndrome and pacemaker, included interventions initiated on 2/16/2024 for administering medications and watch for signs of bleeding. The Care Plan lacked interventions about the device to monitor the pacemaker. During an observation on 4/2/2024 at 9:15 am in R31's room, on a table located against the wall opposite the bed a device was plugged into the wall. The label on the device listed the (Name of the remote management system). There was a phone number for assistance label on top of monitoring device, plugged into wall socket and green light on in the bottom right corner of the device. During an interview on 4/4/2024 at 10:05 am, Licensed Practical Nurse (LPN)2, who was providing care for R31, stated she did not know what the device did or anything about the purpose of the device located in R31's room and confirmed the resident's Care Plan lacked documentation of the device. During an interview on 4/4/2024 at 12:34 pm, Registered Nurse (RN)1 verbalized the Care Plan for R31 should have been updated when the device was brought into the facility and staff should have occasionally confirmed the signal was being sent to the cardiologist office. During an interview on 4/4/2024 at 1:30 pm, the Assistant Director of Nursing (ADON) explained the device was brought to the facility after a cardiology appointment by FM2, it was a remote monitor, and the only requirement was to be plugged into the wall. The ADON confirmed the remote monitoring device for the pacemaker should have been updated on R31's Care Plan when it was brought into the facility. During an interview on 4/4/2024 at 1:18 pm, the Director of Nursing (DON) confirmed information about the monitoring device was not included on R31's Care Plan, and once the monitoring device came into the facility it should have been added to the Care Plan. 2. Review of a document provided by the facility titled, Face Sheet indicated R1 was admitted to the facility with a diagnosis of a traumatic head injury. Review of a document provided by the facility titled, Care Plan, dated 8/31/2020, indicated R1 had short- and long-term memory problems. Review of a document provided by the facility titled, Care Plan Conference, dated 10/24/2023, indicated the family member of R1 was invited to participate in his care conference and did not attend. The document failed to indicate if R1 was invited to participate in his quarterly care conference. Review of a document provided by the facility titled, quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 12/20/2023, indicated R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated led the resident was moderately cognitively impaired. Review of a document provided by the facility titled, Care Plan Conference dated 1/23/2024 indicated the family of R1 was invited to participate in his care conference and did not attend. The document failed to indicate if R1 was invited to participate in his quarterly care conference. During an interview on 4/2/2024 at 9:18 am, R1 stated he did not get invited to his quarterly care conferences. During an interview on 4/3/2024 at 1:11 pm, the Social Services Director (SSD) stated the MDS Coordinator would send out invitations to the residents' representatives on a quarterly basis and would always invite the residents. The SSD did not invite the resident to attend the Care Plan Conference. During an interview on 4/3/2024 at 2:14 pm, the MDS Coordinator stated all the resident representatives were sent invitations. The MDS Coordinator stated the SSD would invite the residents to their quarterly care plan meetings. The MDS Coordinator did not invite the resident to attend the Care Plan Conference. During an interview on 4/4/2024 at 4:52 pm, the Director of Nursing (DON) stated her expectation was for the residents and their family members to be invited to quarterly care conferences and the facility does send out invitations. 39540

Based on observations, staff interviews, record review, and review of the facility's policy titled, Using A Portable Lifting Machine, the facility failed to ensure a mechanical lift sling was inspected for damage and defects after laundering for one out of five residents (R) (R13) reviewed for falls. The deficient practice caused R13 to fall from a mechanical lift sling because of a broken strap while being transferred from his motorized wheelchair to the bed. Findings include: Review of the facility's policy titled, Using A Portable Lifting Machine, dated 12/29/2023, provided by the facility, revealed, Various manual and/or electric mechanical lifts may be used by this center. Manufacturer recommendations for use should be followed. Review of the manufacturer guidelines titled, Liko (Trademark) Soft Original High Back Sling, Mod. 26 Instructions for Use, dated 12/11/2013, provided by the facility, revealed Care and Maintenance of Liko Slings . Check the Sling after Washing. All points are inspected with regard to wear and damage Fabric, Straps, Seams, Suspension loops, Buckles (where applicable) . Do not use damaged slings. Protocol for periodic inspection can be used as guidance as to which parts are extra important to check for each sling model. Slings in polyester fabric have a longer lifetime than slings in net polyester. The handles on certain slings are intended for steering. Too heavy a load on the handles can result in the sling breaking. Review of R13's undated Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R13 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (CP) and morbid obesity. Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/2023 located in the EMR under the MDS tab, revealed R13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment indicated R13's functional status as being dependent on staff for transfers, and he used a motorized wheelchair. Review of R13's Care Plan, dated 10/6/2023, located in the EMR under the Care Plan tab, indicated R13 fell on [DATE] with an intervention on 10/2/2023 of 911 call [sic], MD [physician] notified, Sent to ER [emergency room ], Neuro [neurological] check and an intervention on 10/6/2023 of Slings evaluated and blue sling appropriate for use. Review of R13's Nursing Progress Notes, dated 10/2/2023, located in the EMR under the Progress Notes tab, indicated 0305 [3:05 AM]-Staff was putting resident to bed when strap on lift seat [sling] broke and resident fell to floor with legs still in lift seat. Back was lying across leg of lift with head on floor. Lift lowered and sling removed. Resident rolled off leg of lift onto floor. Pillow under head, No Loc [loss of consciousness]. Resident c/o [complained of] pain to back. Able to MAEW [move all extremities well]. 0359 [3:59 AM] 911 notified. 0401 [4:01 AM]-Dr [doctor] and on call notified 0402 [4:02 AM]-Neuro check WNL [within normal limits]. 0410 [4:10 AM]-EMS [emergency medical services] here. Awaiting additional personel [sic]. 0430 [4:30 AM]-Resident to [hospital] via stretcher. 0431 [4:31] AM-Report called to RN [registered nurse] at [hospital]. During an interview on 4/2/2024 at 11:01 am, R13 stated on 10/2/2023, three-night shift staff--two Certified Nursing Aides (CNAs) and one RN--were in the process of transferring him from the motorized wheelchair to his bed when the upper right strap of the sling ripped and broke. His head fell to the floor, but his legs stayed in the sling. R13 also stated he had pain in his neck and back, he was sent to the hospital, and he had no injuries. During an interview on 4/2/2024 at 3:06 pm, the Administrator stated R13 fell from the mechanical lift when the right upper strap broke when three staff were moving him from the wheelchair to the bed on 10/2/2023. The Administrator also stated R13 was sent to the hospital because he complained of pain but did not suffer any injuries. The Administrator indicated the cause of the broken sling could not be determined; however, the investigation revealed the laundry staff did not document that mechanical lift slings were inspected for defects or damage prior to putting them back in circulation on the floor prior to R13's fall. The Administrator confirmed no other incidents had occurred before or after R13's fall but she removed those slings and ordered new slings for all the residents. During an interview on 4/2/2024 at 3:17 pm, the Housekeeping Supervisor stated the laundry staff washed and hung the mechanical lift slings to dry then sent them to floor or stored them in storage bins but did not check them for damage or defects or document it until after R13's fall on 10/2/2023. The Housekeeping Supervisor also stated laundry staff now inspect every sling after they were laundered, and they documented the inspection on the Mechanical Lift Inspection Log. During an interview on 4/3/2024 at 11:54 am, Laundry Aide 1 stated that after the mechanical lift slings were laundered, they were inspected for damage, and they documented it on the sling log, but that process did not begin until after R13's incident last year. Laundry Aide 1 also stated if the slings were damaged, they removed the sling and gave it to the Housekeeping Supervisor.

Based on observation, interview, and record review, the facility failed to ensure staff were informed or educated about the remote cardiac monitor's purpose for one of one Resident (R) (R 31) with a pacemaker monitor. The deficient practice had the potential to place R31 at risk of not receiving necessary care and monitoring for cardiac instability. Findings include: Review of the Facility Assessment, dated 3/6/2024, revealed Education is conducted on our L.E.A.D. platform which is assigned monthly by (Name of Company) and on an as needed basis for individuals and groups. L.E.A.D. assignments are conducted based on QAPI processes and annual education requirements for regulatory purposes. Other training needs are addressed through On-boarding and orientation-Annua/Skills Fair (completed in May 2023), Safety Boot Camp, Webinars, Staff Meetings, Huddles and (Name of Company). Notifications. (Name of Company) consultants conduct education during site visits and via Zoom meetings. Outside education is offered through GHCA, AHCA, Healthcare Coalitions and (Name of Company) training and meetings off-site. The Facility Assessment did not identify cardiac pacemaker monitoring equipment or staff training needed for use of the device. Review of the undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R31 was admitted with diagnoses including sick sinus syndrome, left bundle branch block, and presence of a cardiac pacemaker. Review of R31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/2024 and located in the EMR under the MDS tab, revealed a Brief Interview of Mental Status (BIMS) score of 99, which indicated severe cognitive impairment. R31's diagnoses included heart failure and hypertension. Review of the Care Plan tab in the EMR under the focus area for anticoagulant related to left bundle branch block, sick sinus syndrome and pacemaker, included interventions initiated on 2/16/2024 for administering medications and watch for signs of bleeding and lacked interventions about the device to monitor the pacemaker. During an observation on 4/2/2024 at 9:15 am, in R31's room, on a table located against the wall opposite the bed a device was plugged into the wall. The label on the device was (Name of the remote management system). There was a phone number for assistance label on top of monitoring device, plugged into wall socket and green light on in the bottom right corner of the device. During an interview on 4/2/2024 at 9:59 am, R31's Family Member (FM)1 explained the device was a monitor that sent information about the heart rhythm and pacemaker to the cardiologist's office for evaluation. During an interview on 4/4/2024 at 10:05 am, Licensed Practical Nurse (LPN)2, who was providing care for R31, stated she did not know what the device did or anything about the purpose of the device located in R31's room. During an interview on 4/4/2024 at 1:30 pm, the Assistant Director of Nursing (ADON) explained the device was brought to the facility after a cardiology appointment, it was a remote monitor, and the only requirement was to be plugged into the wall. During an interview on 4/5/2024 at 1:55 pm, R31's FM2 explained during the visit with the cardiologist and R31 in December 2023, the device was provided to monitor the pacemaker due to the battery being very low (implanted in 2016). The cardiologist's office would notify the facility if there were issues with the battery or cardiac rhythm. FM2 brought the device to the facility to monitor R31's cardiac stability. During an interview on 4/5/2024 at 9:17 am, Licensed Practical Nurse (LPN)3 confirmed FM2 brought the device into the facility to monitor the pacemaker of R31 to set up for monitoring. LPN3 plugged in the device and called the customer service number to set up the monitor. The responsibility of the facility was to be sure the device was plugged in, green light on in the bottom right corner, and placed in the resident room. LPN3 stated since the device was already set up, she did not communicate information about the device to any other staff. During an interview on 4/5/2024 at 12:23 pm, the Director of Nursing (DON) verbalized staff development and training was performed as a group project involving the DON, ADON, supervisors, and other staff as needed. The DON confirmed no education was provided for the device in R31's room for monitoring the cardiac health of the resident when the device was brought into the facility, but training should have been done to ensure all staff could provide the necessary care for the monitor.

Based on observations, record review, staff interviews, and review of the facility policy titled Skilled Inpatient Services - ADL Plan of care, the facility failed to follow the care plan for eight residents (R) (R#26, R#35, R#43, R#7, R#23, R#27) related to activities of daily living (ADL), R#19 related to falls, and R#24 related to elevated finger stick blood sugar levels. The sample size was 33. Findings include: Review of policy titled Skilled Inpatient Services ADL Plan of Care reviewed on 12/4/2021 revealed the intent is to develop and communicate patient needs for assistance with ADLs. The policy stated ADLs are assessed on admission for each resident, addressed on the baseline care plan, and communicated to the staff. Nursing is responsible for development of care plan and communication of level of assistance residents require. 1. Review of the clinical record revealed R#26 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, blindness, anxiety disorder, major depressive disorder, need for assistance with personal care, muscle weakness, diabetes mellites type 2. The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was 15, which indicated no cognitive impairment. Review of the care plan updated 2/7/2023 revealed resident has limited mobility related to need for assistance with functional activities of daily living (ADLs). Interview on 2/14/2023 at 2:45 p.m. with CNA MM revealed all residents have a care plan which the CNA's can access to review and obtain the residents functional ability and the assistance level they require. She revealed she makes rounds every two hours and provides incontinent care to residents when needed during rounds. Interview on 2/14/2023 at 3:11 p.m. with CNA NN revealed the residents care plan indicates the level of assistance each resident needs with ADL's. She revealed CNA's make rounds every two hours and all residents who are incontinent are checked during these rounds and perineal care is provided as needed. 38154 2. Review of the clinical record revealed R#35 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident (CVA) with left hemiplegia, gastroesophageal reflux disease (GERD), and major depressive disorder. Review of the annual MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Review of the Care Plan updated 1/1/2023 revealed the resident has self-care deficit related to the need for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation/interview on 2/15/2023 at 11:03 a.m., R#35., she stated she did not receive a shower yesterday. Observation/interview with R#35 on 2/16/23 at 3:55 p.m., she stated she had not received a shower this week, although she did get a bed bath yesterday. Interview on 2/15/2023 at 10:00 a.m., LPN JJ stated staff should be making rounds every two hours and as needed to provide care and service. 3. Review of the clinical record revealed R#43 was readmitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the Admission MDS dated [DATE], revealed a BIMS of 11, indicating mild cognitive impairment. Review of the care plan dated 2/5/2023 revealed the resident has a self-care deficit related to a need for assistance with personal care and needs assistance with toileting hygiene. Interview on 2/15/2023 at 10:40 a.m., LPN II stated staff should make resident rounds every two hours and as needed and answer call lights as soon as possible. Interview on 2/15/2023 at 1:40 p.m., CNA HH stated staff should make resident rounds every two hours and as needed to provide a check and change. 46579 4. Review of the clinical record revealed R#27 was admitted to the facility with diagnoses that include but not limited to Alzheimer's Disease, Diseases of gallbladder, recurrent major depressive disorder, hypothyroidism, dysphagia, morbid obesity, chronic viral hepatitis C, and hypertension (HTN). Review of the quarterly MDS 1/1/2023 revealed a BIMS score of 99, which indicates severe cognitive impairment. Review of the Care Plan updated 1/17/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation on 2/14/2023 at 10:20 a.m. notification at the head of resident's bed posted by the family as a reminder for the staff to brush resident's teeth and offer fluids. Surveyor unable to locate a toothbrush in residents' room or bathroom. When asked if her teeth had been brushed today, resident shook her head no. Interview on 2/14/2023 at 2:46 p.m. and 2/15/2023 at 10:08 a.m., R#27 denied that staff had provided oral hygiene for her. Interview on 2/15/2023 at 10:09 a.m. CNA EE stated that she did not brush resident's teeth before or after breakfast. She stated that she is aware of the signage indicating residents' teeth needed to be brushed but stated she has never brushed her teeth. 45813 5. Review of the clinical record revealed R#23 was admitted to the facility on [DATE] with diagnoses that include but not limited to systolic (congestive) heart failure, bradycardia, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), difficulty in walking, need for assistance with personal care, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly MDS Quarterly dated 1/11/2023 revealed a BIMS score of five, which indicates severe cognitive impairment. Review of the Care Plan updated 1/27/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation on 2/13/2023 at 12:03 p.m. revealed resident was observed with facial hair that was unkempt and not shaved. There was tobacco spit/juice on his facial hair. He had tobacco crumbs and spit juice on his shirt and pants. Resident's fingernails had a dark substance underneath. Observation on 2/14/2023 at 10:08 a.m. and 2:26 p.m. resident observed to be unkempt with long facial hair with tobacco spit and juice in his facial hair. Resident has a large amount of an unknown white substance on his shirt and pants, fingernails remain dirty, hair is disheveled. Observation and interview on 2/15/2023 at 9:51 a.m. R#23 continued to have long facial hair and dirty fingernails. Resident stated he has not been shaved this week or last week. Interview on 2/15/2023 at 10:03 a.m., CNA EE stated R#23 is self-sufficient, but she provides incontinent care for him. CNA EE confirmed that she had not offered R#23 a bath, shave, or to have his fingernails cleaned today. 6. Review of the clinical record revealed R#27 was admitted to the facility with diagnoses that include but not limited to Alzheimer's Disease, Diseases of gallbladder, recurrent major depressive disorder, hypothyroidism, dysphagia, morbid obesity, chronic viral hepatitis C, and hypertension (HTN). Review of the quarterly MDS 1/1/2023 revealed a BIMS score of 99, which indicates severe cognitive impairment. Review of the Care Plan updated 1/17/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation on 2/14/2023 at 10:20 a.m. notification at the head of resident's bed posted by the family as a reminder for the staff to brush resident's teeth and offer fluids. Surveyor unable to locate a toothbrush in residents' room or bathroom. When asked if her teeth had been brushed today, resident shook her head no. Interview on 2/14/2023 at 2:46 p.m. and 2/15/2023 at 10:08 a.m., R#27 denied that staff had provided oral hygiene for her. Interview on 2/15/2023 at 10:09 a.m. CNA EE stated that she did not brush resident's teeth before or after breakfast. She stated that she is aware of the signage indicating residents' teeth needed to be brushed but stated she has never brushed her teeth. 7. Review of the clinical record revealed R#19 was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's Disease, difficulty in walking, muscle weakness (generalized), need for assistance with personal care, osteoarthritis of knee, cramp and spasm, age-related osteoporosis without current pathological fracture. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the care plan updated 2/14/2023 indicated resident is a fall risk related to difficulty in walking, generalized muscle weakness, unsteadiness on feet and unsteady gait. The interventions listed includes assess contributing factors related to fall history, place patient in open area for maximum observation, place back to bed, and non-skid strips to both sides of bed. Observation on 2/14/2023 at 10:32 a.m. revealed resident out of bed to wheelchair in her room at the end of the hall. Resident has a walker positioned in front of her. Observation on 2/14/2023 at 12:11 p.m. revealed resident in her room at the end of the hall, sitting in her wheelchair. She was asleep and leaning forward in her wheelchair. Interview on 2/14/2023 at 12:29 p.m. CNA CC revealed she saw resident at approximately 11:45 a.m. sitting in her room in the wheelchair sleepy and nodding off. CNA CC stated that she did not ask resident if she wanted to lie down for a nap or attempt to assist her to another area to be monitored because it just did not dawn on her to do that. CNA CC further stated that she is aware that resident is a high-risk for falls because her name is on the list that she has. Interview on 2/14/2023 at 12:55 p.m. with Director of Nursing Services (DNS) revealed her expectation is that if a resident with a history of falls is in a wheelchair asleep, that the staff should assist the resident to bed. She further stated residents that are high risk for falls be placed in a frequently observed area such as the nurse's station or dining room, to be monitored. 44960 8. Review of the clinical record revealed R#24 was admitted to the facility on [DATE] with diagnoses including congested heart failure (CHF), chronic obstruction pulmonary disease (COPD), acute respiratory failure, diabetes mellitus, and restless leg syndrome. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of nine out of 15, which indicated moderate cognitive impairment. Review of the care plan dated 2/1/2023 revealed resident has diagnosis of diabetes mellitus with persistent elevation in fingerstick blood sugars (FSBS). Interventions to care include administer insulin and/or oral hypoglycemics as ordered and notify Physician as indicated. Interview on 2/16/2023 at 1:58 p.m., the DON verified there was no evidence in the EMR that physician was informed about elevated FSBS on 1/26/2034 and 1/30/2023. Interview on 2/16/2023 at 3:30 p.m. with the DON revealed CNA's can access residents care plan to determine the level of assistance required for each resident. The expectation is that the CNA follow the care plan and provide care for each resident as directed by the care plan.

Based on observations, record review, interviews, and review of the policy titled Skilled Inpatient Services -ADL Plan of Care, the facility failed to provide activities of daily living (ADL) care for six residents (R) (R#26, R#35, R#43, R#23, R#27, R#7). The sample size was 33. Findings included. Review of the policy titled Skilled Inpatient Services -ADL Plan of Care dated 12/4/2021, indicated the intent is to develop and communicate patient needs for assistance with ADLs. Guideline: Nursing develops the patient's ADL care plan and will communicate the level of assistance required for the patient. 1. Review of the clinical record revealed R#26 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, blindness, anxiety disorder, major depressive disorder, need for assistance with personal care, muscle weakness, diabetes mellites type 2. The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was 15, which indicated no cognitive impairment. Section G revealed that the resident was assessed for extensive to total dependance with one to two-person assistance required for activities of daily living (ADL). Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan updated 2/7/2023 revealed resident has limited mobility related to need for assistance with functional activities of daily living (ADLs). Interventions to care include assist with ADLs as needed and provide level of assistance to promote safety. Review of grievances filed by resident on 8/9/2202 revealed resident stated he did not receive a bed bath as scheduled; and on 2/6/2023 resident stated staff was rushing to complete his bed bath. Review of the grievances revealed resident was satisfied with the outcome of each grievance. Review of Facility Reported Incident dated 11/3/2022 indicated resident stated he is being neglected by staff by not responding to the call-light and not taking care of him at night in a timely manner. Facility investigation revealed interviews from staff assigned to care for resident and other residents. There is no documentation regarding the outcome of the facilities investigation into this complaint of neglect. Review of the weekly shower schedule provided by the Director of Nursing (DON) revealed R#26 was bathed one time the week of 1/23/2023, none the week of 1/30/2023, one time the week of 2/6/2023, and as of 2/15/2023 no baths were recorded for the week of 2/12-2/18/2023. Interview on 2/14/2023 at 2:52 p.m. with Licensed Practical Nurse (LPN) JJ stated if a resident is requesting care, the CNA assigned to that resident is notified of residents need. During further interview, LPN JJ stated if the assigned CNA is unable to attend to the resident, then the person who answered the call light would tend to the resident's request/needs. Interview on 2/14/2023 at 2:45 p.m. with CNA MM revealed she makes rounds every two hours and provides incontinent care to residents when needed during rounds. She stated R#26 receives his baths on Monday's and Fridays. During further interview, she stated she was unaware of a bath log or where to locate documentation of baths. Interview on 2/14/2023 at 3:11 p.m. with CNA NN revealed CNA's make rounds every two hours and all residents who are incontinent are checked during these rounds and perineal care is provided as needed. During further interview she stated there is a bath schedule posted at the nursing desk. She stated all baths and care given should be documented in the EMR. Interview on 2/14/2023 at 4:17 p.m. with CNA/CMA CC revealed there is a shower sheet kept in the shower room, but she was unsure if anyone documents on it. She stated they obtain a vital sign sheet and as they complete baths, they mark it on this sheet and at the end of shift they place this sheet under the DON's office door. Interview on 2/15/2023 at 3:30 p.m. with the DON revealed there is no documentation in the EMR for R#26 receiving a bath. She stated she is aware that the CNA's are not documenting care provided and has been providing education to them regarding documenting the care provided to residents. During further interview, she stated if residents refuse their bath, they should be documenting the refusal, and the resident should be care planned for refusal of care. She stated her expectation is that when care is given, the CNA should chart care in the EMR. 38154 2. Review of the clinical record revealed R#35 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident (CVA) with left hemiplegia, gastroesophageal reflux disease (GERD), and major depressive disorder. Review of the annual MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Section G revealed she required total care of two-persons for all activities of daily living (ADLs). Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the Care Plan updated 1/1/2023 revealed the resident has self-care deficit related to the need for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed, refer to ADL POC for levels of assistance needed. Review of the Unit Three Weekly Shower Schedules dated 1/23/2023 through 2/12/2023 revealed R#35 was scheduled for showers twice weekly on Tuesday and Friday. The shower schedules documented she received showers on 1/24/2023, 2/6/2023, and 2/9/2023. There were no refusals documented. Observation/interview on 2/13/2023 at 11:35 a.m. R#35 in her room, stated she has had to wait for toileting and ADL care from one to one and half hours. Observation/interview on 2/14/2023 at 11:19 a.m., R#35 stated she had one shower last week, but stated they had not been consistent, and she did not receive bed baths. Observation/interview on 2/15/2023 at 11:03 a.m., R#35., she stated she did not receive a shower yesterday. Observation/interview on 2/16/23 at 3:55 p.m., R#35 stated she had not received a shower this week, although she did get a bed bath yesterday. Interview on 2/13/2023 at 1:35 p.m., CNA VV and CNA WW stated residents were scheduled for showers twice a week. Further interview revealed they had not given any showers so far today. They stated they should report all refusals or omissions to the nurse. Interview on 2/15/2023 at 10:00 a.m., LPN JJ stated staff should be making rounds every two hours and as needed to provide care and service. He stated showers should be given twice a week and as needed. He stated staff should report refusals to the nurse who should check the resident and confirm the refusal and try to talk the resident into accepting care. During further interview, he stated no one reported to him that R#35 refused a shower or that the shower was omitted. 3. Review of the clinical record revealed R#43 was readmitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the Admission MDS dated [DATE], revealed a BIMS of 11, indicating mild cognitive impairment. Section G revealed resident was total dependence of two-persons for all ADLs. Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan dated 2/5/2023 revealed the resident has a self-care deficit related to a need for assistance with personal care and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed and see ADL POC for assistance levels. Review of the Unit One Weekly Shower Schedules dated 1/23/2023 through 2/12/2023 revealed R#43 was scheduled for showers twice weekly on Wednesday and Saturday. The shower schedules revealed he had not received any showers and there were no refusals documented. Interview on 2/14/2023 at 2:20 p.m., R#43 revealed he could not remember the last time he had a shower. Interview on 2/15/2023 at 10:25 a.m., R#43 stated he still had not had a shower. Interview on 2/15/2023 at 10:40 a.m., LPN II stated staff should make resident rounds every two hours and as needed and answer call lights as soon as possible. She stated showers are scheduled twice a week. She stated if a resident refused a shower, the staff should report it to the nurse and document on the shower sheet. Interview on 2/15/2023 at 1:40 p.m., CNA HH stated staff should make resident rounds every two hours and as needed to provide a check and change. She stated she tries to give her residents bed baths daily and tries to get her residents their scheduled showers if time and staffing permit. Interview on 2/15/2023 at 9:47 a.m., Assistant Director of Nursing (ADON) reviewed the Weekly Shower Schedules beginning 1/23/2023 through 2/12/2023. She stated staff document showers performed by crossing out the room number, refusals with a circle around the room number, and leaving the room number undisturbed if the shower was omitted. During further interview, she stated she and the DON are responsible for checking the shower sheets for compliance because they recognized either a lack of showers performed and/or a lack of documentation. She concluded that they had not had the opportunity to check the shower sheets for this week. 45813 4. Review of the clinical record revealed R#23 was admitted to the facility on [DATE] with diagnoses that include but not limited to systolic (congestive) heart failure, bradycardia, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), difficulty in walking, need for assistance with personal care, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly MDS Quarterly dated 1/11/2023 revealed a BIMS score of five, which indicates severe cognitive impairment. Section G revealed resident is total dependent of two-persons for bathing and personal hygiene. Section F was incomplete for preferences for care. Review of the Care Plan updated 1/27/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed, assist with oral hygiene after meals and as needed, assist with showers/baths, and refer to ADL POC for levels of assistance needed. Review of the Unit Three Weekly Shower Schedules dated 1/23/2023 through 2/12/2023 revealed R#23 was scheduled for showers twice weekly on Tuesday and Friday, with Sunday as the make-up day, to double check nails and trim. The shower schedules documented he received a bed bath on 2/6/2023. There were no refusals documented. Review of the ADL documentation in the EMR revealed one documented bath on 1/19/2023. The DON confirmed there was no other documentation for showers/baths. Review of nurse's progress notes from 1/1/2023 through 2/15/2023 revealed no documentation regarding refusal of ADL care or baths/showers. Observation on 2/13/2023 at 12:03 p.m. revealed resident sitting in his wheelchair watching television. He was observed with facial hair that was unkempt and not shaved. There was tobacco spit/juice on his facial hair. He also had tobacco crumbs and spit juice on his shirt and pants. Resident's fingernails had a dark substance underneath. Observation on 2/14/2023 at 10:08 a.m. and 2:26 p.m. resident observed out of bed sitting in the wheelchair. Resident observed to be unkempt with long facial hair with tobacco spit and juice in his facial hair. Resident has a large amount of an unknown white substance on his shirt and pants, fingernails remain dirty, hair is disheveled. Observation and interview on 2/15/2023 at 9:51 a.m. R#23 continued to have long facial hair and dirty fingernails. Resident stated he has not been shaved this week or last week. He stated that he likes to be bathed in the bed but has not had a bath because they don't do anything to help him. During further interview, resident stated that his fingernails are cleaned when he gets his bath but stated he has not had a bath in a while. Interview on 2/15/2023 at 10:03 a.m., CNA EE stated R#23 is self-sufficient, but she provides incontinent care for him. She stated resident was already out of bed when she arrives for her shift. She stated she had not looked at the shower sheet to see if R#23 needed to be showered, shaved, or his fingernails cleaned, but she provided incontinent care. CNA EE stated resident refuses care at times, and when he does, she asks a second time, if he continues to refuse, she reports the refusal to the nurse. CNA EE confirmed that she had not offered R#23 a bath, shave, or to have his fingernails cleaned today. Interview on 2/15/2023 at 9:47 a.m., the ADON after reviewing this week's bath/shower sheets, confirmed that CNAs have not documented shower or bed baths done for this week. She stated that she and Director of Nursing (DON) are responsible for checking the shower sheets for compliance. During further interview, she stated she has not had the opportunity to check the sheets this week. Interview on 2/15/2023 at 10:27 a.m. with LPN JJ, revealed he has worked on the 300 hall all week. He stated the CNAs had not reported refusal of care for R#23 for this week. He further stated that if a R#23 refuses care, he will talk to him and encourages resident to comply, and stated he usually he does. During further interview, LPN JJ stated that if a resident refuses care, it is documented in the nurse's progress notes. Observation and interview on 2/15/2023 at 10:36 a.m., DON verified that R#23 hair had not been combed, his fingernails were not clean, and he had not been shaved. She stated that resident sometimes refuses care, but it should be documented by the CNAs and the Nurses. During further interview, she stated R#23 dips tobacco and that has caused his hygiene issues, but stated the staff should be offering to clean him up. R#23 agreed to receive a bed bath and shave at this time. The DON concluded that the implemented process for ADL care and showers is not working and will have to be revised. 5. Review of the clinical record revealed R#27 was admitted to the facility with diagnoses that include but not limited to Alzheimer's Disease, Diseases of gallbladder, recurrent major depressive disorder, hypothyroidism, dysphagia, morbid obesity, chronic viral hepatitis C, and hypertension (HTN). Review of the quarterly MDS 1/1/2023 revealed a BIMS score of 99, which indicates severe cognitive impairment. Section G revealed resident is total dependent on two-persons ADL care. Section F was incomplete for preferences for care. Review of the Care Plan updated 1/17/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed and refer to ADL POC for levels of assistance needed. Review of the EMR ADL documentation revealed there is not a specific area where mouth care is documented. Observation on 2/14/2023 at 10:20 a.m. notification at the head of resident's bed posted by the family as a reminder for the staff to brush resident's teeth and offer fluids. Surveyor unable to locate a toothbrush in residents' room or bathroom. When asked if her teeth had been brushed today, resident shook her head no. Interview on 2/13/2023 at 1:26 p.m. resident's daughter stated the staff does not brush her mother's teeth. She stated that she posted signs in the resident's room to remind staff to brush her mother's teeth and they still do not brush her teeth. During further interview, daughter stated resident had two teeth removed for lack of oral care by the facility. Interview on 2/14/2023 at 2:46 p.m. and 2/15/2023 at 10:08 a.m., R#27 denied that staff had provided oral hygiene for her. Interview on 2/15/2023 at 10:09 a.m. CNA EE stated that she has provided feeding assistance, incontinent care and obtained vital signs for R#27 today. CNA EE stated did not brush resident's teeth before or after breakfast. She stated that she is aware of the signage indicating residents' teeth needed to be brushed but stated she has never brushed her teeth. At this time, CNA EE searched residents' room for a toothbrush and located an unused toothbrush and verified the toothbrush was new and has never been used. The CNA verified that R#27 had not refused mouth care, and stated she has never offered to brush her teeth for her. Interview on 2/15/2023 at 1:35 p.m., Social worker (SW) revealed that she is responsible for the Dental Services at the facility. She stated that the residents receive dental services through [provider], and revealed they visited the facility on 1/17/2023. She stated that R#27 was seen at that time and will be seen at the next scheduled visit for extractions. The SW stated the CNAs working on the floor are responsible for making sure resident's teeth are brushed and this is a part of their ADL care. Interview on 2/15/2023 at 10:29 a.m., DON revealed that she was not aware that resident was not receiving oral hygiene and that R#27 should have her teeth brushed in the mornings and after each meal. Telephone interview on 12/16/2023 at 10:09 a.m. Hospice Aide (HA) FF stated that R#27 has been on her caseload since 2021. She stated that she provides care R#27 two-three times per week. During further interview, HA FF stated she uses lemon glycerin swabs to clean residents' mouth when needed, but stated she has never brushed her teeth. 46579 6. Review of clinical record revealed R#7 was admitted to the facility on [DATE] with diagnoses that include but are not limited to absence epileptic syndrome, moderate intellectual disabilities, schizoaffective disorder, depressive, type 2 diabetes mellitus, and muscle weakness. Review of the quarterly MDS 11/18/2022 revealed a BIMS score of five, which indicates severe cognitive impairment. Section G revealed resident is total dependent on two-persons ADL care. Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the Care Plan updated 12/2/2022 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include encourage resident to participate in ADLs and praise accomplishments, give as many choices as possible about care, assist with ADLs as needed, break tasks down into manageable segments, and refer to ADL POC for levels of assistance needed. Observation on 2/13/2023 at 11:10 a.m. revealed resident was in the bed, with eyes open and head of bed up. Her fingernails were dirty with brown substance and her gown was dirty. Observation on 2/14/2023 at 10:28 a.m. revealed resident in the bed, gown is still dirty, and fingernails are still dirty. Observation on 2/14/2023 at 4:22 p.m. residents' gown was still dirty, fingernails were dirty with dark substance and fingers dirty with Cheetos cheese powder. Observation on 2/15/2023 at 11:31 a.m., Resident's gown was clean, but her fingernails were still dirty. Interview on 2/15/2023 at 12:15 p.m., CNA TT verified R#7's fingernails were dirty. She stated resident got a bed bath this morning. She stated that she should have soaked her fingernails to clean and trim them. Interview on 2/15/2023 at 4:11 p.m. DON revealed that nail care, mouth care, and shaving are activities of daily living and should be completed during baths and/or showers. She also stated the CNAs should be completing shower sheets to indicate the care provided. During further interview, she indicated if residents room number is crossed out on the shower sheet, it means the bath or shower was completed, it the room number is circled, it was refused by the resident, and if the room number was left alone, nothing was not done at all.

Based on observations, record review, interviews, and review of facility policies, the facility failed to implement an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced infection control standards during wound care for two residents (R) (R#43 and R#71) and by not storing respiratory supplies properly for one resident (R#18). The census was 75. 1. Review of the policy titled Skilled Nursing Services Wound Care revised 10/11/2022 revealed the intent is to provide guidelines for clean technique in providing wound care. Start with a clean surface and a clean tray, using approved cleanser and observing appropriate wet times. Cover the tray with an impervious barrier. Prepare the supplies on the tray with the barrier. Upon entering room, place tray on a clean surface. If the resident is soiled, wound care should not be completed until the resident is clean. Review of the clinical record revealed R#43 was readmitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the Admission MDS dated [DATE], revealed a BIMS of 11, indicating mild cognitive impairment. Section G revealed resident was total dependence of two-persons for all ADLs. Section M revealed four stage two pressure ulcers. Review of the resident's care plan reviewed 1/19/2023 revealed resident is at risk for skin breakdown, stage three pressure ulcer to sacral region. Interventions to care include referral for wound care and treatment/dressings as ordered. Observation on 2/14/2023 at 10:52 a.m. wound care with Treatment Nurse/Registered Nurse (RN) KK assisted by Licensed Practical Nurse (LPN) WW for R#43, revealed RN KK prepared a tray with a barrier, gathered supplies, and placed them on the tray, knocked on resident's door explained the procedure and obtained permission to proceed. The RN KK set up wound care tray on residents' bedside table. He did not remove any items from the bedside table and did not clean the bedside table before placing the tray onto the bedside table. He placed the tray on the bedside table next to residents' 20-ounce soda. He proceeded with dressing change. Hand hygiene was performed, and gloves donned, and doffed appropriately throughout the procedure. Wound treatment completed per orders, removed gloves, and performed hand hygiene. He donned clean gloves, removed, and secured trash bag, and placed new trash bag in trash can. Interview on 2/14/2023 at 11:00 a.m., RN KK confirmed he did not clean the bedside table prior to placing the wound care tray on it, and stated he should have removed residents belongings from the bedside table prior to starting the dressing change. At this time, LPN WW verified and confirmed that the bedside table was not cleansed, and residents' soda and other belongings were not removed from the bedside table prior to the dressing change. During further interview, both nurse's acknowledged the bedside table should have been cleaned and residents' personal items should have been removed, and a barrier applied to the table prior to placing dressing supplies on the table. Interview on 2/16/2023 at 1:00 p.m., the Director of Nursing (DON) revealed the wound care nurse should prepare the surface in which they plan to use to set their supplies on. This includes removing of items from the table, clean surface, use a covered tray which they bring the supplies into the room on, and place covered tray onto a clean work area. 2. Review of the clinical record revealed R#71 was admitted to the facility on [DATE] with diagnoses including fracture of left femur, difficulty in walking, muscle weakness, unsteadiness on feet, need for assistance with personal care, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Section G revealed she was totally dependent on staff for all care. Section M revealed one stage three pressure ulcer. Review of the resident's care plan reviewed 12/29/2022 revealed resident is at risk for skin breakdown, stage three pressure ulcer to sacral region. Interventions to care include referral for wound care and treatment/dressings as ordered. Observation on 2/14/2023 at 12:39 p.m. wound care with RN KK, prepared bedside table with facility approved wipes prior to procedure, then applied a barrier to the table. RN KK performed hand hygiene and obtained supplies needed for dressing change and placed on a tray with a barrier cover. He entered residents' room and placed tray of supplies with barrier on bedside table. He performed hand hygiene, donned gloves, and assessed resident for pain. RN KK removed soiled dressing and resident began displaying nonverbal cues of pain. He stopped treatment to reassess resident for pain. He determined the resident could not tolerate further treatment at this time. It was noted during the removal of the soiled dressing, that resident had dark green soft bowel movement. RN KK reapplied residents depends without performing peri-care or applying a dressing or covering the sacral wound. RN KK communicated to surveyor that next dose of pain medication could be given at 5:00 p.m. at which time he would finish dressing change. Interview on 2/14/2023 at 1:15 p.m. RN KK stated he was concerned about whether it was appropriate to leave the sacral wound uncovered when replacing the brief, when resident was in pain and unable to tolerate the dressing change. Observation on 2/14/2023 at 1:30 p.m., DON and RN KK returned to R#71's room to verify that dressing was not applied to the resident's sacral wound with stool in the depend. Peri-care was performed, and RN KK assessed resident's pain level, and wound care was provided appropriately. Interview on 2/14/2023 at 1:36 p.m., the DON stated her expectation when residents are having pain is the dressing change should be stopped, and stated the wound should not be left uncovered, or covered with a depend. She stated she expects peri-care be done and then reattempt to perform wound care. 45813 3. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral palsy, pulmonary embolism with acute cor pulmonale, obstructive sleep apnea (OSA), retention of urine, glaucoma, essential (primary) hypertension, hyperglyceridemia, major depressive disorder, and Hyperlipidemia. Review of quarterly MDS dated [DATE], revealed a BIMS score of 15, indicating no cognitive impairment. Section G was coded total dependence for ADLs. Section O indicated the use of BIPAP. Review of the care plan initiated on 12/16/2022, revealed resident had respiratory difficulties/risk for further decline related to BIPAP and diagnosis of other pulmonary embolism with acute cor pulmonale and obstructive sleep apnea. Approaches to care include BIPAP as ordered. Review of February Physician Orders (PO) revealed an order dated 2/28/2022 for BiPAP at bedtime IPAP 24---EPAP 14---RR 16. Observation on 2/14/2023 at 2:21 p.m. and 2/15/2023 at 1:41 p.m. revealed R#18's BIPAP mask lying his bed unbagged, uncovered, and exposed to the environment. Interview on 2/14/2023 at 2:45 p.m., R#18 stated he wears the BIPAP at night and stated his mask or tubing has not been cleaned in the last three months, since the respiratory therapist left. Resident stated that the staff does not clean the tubing or the mask of his BIPAP regularly. He stated that the mask is supposed to be washed at least weekly with soap and water but stated they don't ever do it. Interview on 2/15/2023 at 1:46 p.m., LPN II stated the CNAs are responsible for assisting residents with removal and storage of BIPAP mask. She confirmed that BIPAP masks should be kept in a bag when not in use. LPN II verified R#18's BIPAP mask to be lying on the bed, unbagged, uncovered, and exposed to the environment. Interview on 2/15/2023 at 1:52 p.m., CNA HH revealed that she assisted R#18 out of bed around 10:00 a.m. this morning. She stated that she placed that BIPAP mask on the bed, while she was assisting resident with ADLs. During further interview, she stated there is someone assigned to wash the mask and she does not have to deal with the BIPAP mask that much. She stated, Honestly I only clean the BIPAP mask if resident asks me to do so, for instance if it falls on the floor. CNA HH stated that she does not store the mask when it is not in use. Interview on 2/15/2023 at 2:00 p.m., DON revealed that the respiratory consultant comes to the facility every three months and changes the filters and checks the tubing of the BIPAP for wear and tear. During further interview, she stated that CNAs change and clean the tubing every Wednesday night and revealed the BIPAP mask should be stored in a bag when not in use.

Based on observations, record review, policy review, interviews, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality as evidenced by two Licensed Practical Nurses (LPN), administered insulin to R#18, using another resident's insulin pen on two different occasions. The sample size was 33. Findings include: Review of the policy titled, Pharmacy Services: Insulin Administration, copyright 2022, revealed policy guideline - nursing should double-check all insulin therapy before administering. Administration as follows: Patient name and drug order is checked and double-checked. Insulin pen: Never share insulin pens between patients. Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician practicing medicine, a dentist practicing dentistry, a podiatrist practicing podiatry, or a registered nurse practicing nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, dialysis, specialty labs, home health care, or other such areas of practice. (c) Performing comfort and safety measures. (d) Administering treatments and medications by various routes. Review of the Novolog Pen Manufacturer package insert, provided by the consultant pharmacist revised 10/2021 revealed; WARNINGS AND PRECAUTIONS - Never share a NOVOLOG(R) Flex Pen(R) or a NOVOLOG(R) FlexTouch(R), PenFill(R) cartridge or PenFill(R) cartridge device between patients, even if the needle is changed. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral palsy, glaucoma, essential (primary) hypertension, and hyperglyceridemia. Review of R#18's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section G revealed resident requires total dependence for ADLs. Section N indicated the use of insulin injections. Review of the care plan initiated on 12/16/2022, revealed resident had a care area problem of Diabetes Mellitus related to type 2 diabetes and hyperglyceridemia. Resident chooses to not take ordered insulin at times. Interventions to care include accu-checks as ordered, administer insulin and/or oral hypoglycemics as ordered, provide education on blood glucose management, respect residents decision not to take insulin or accu-checks and eat foods of his choice. Review of the February 2023 Physician Orders revealed an orders for reduced concentrated sweets diet, Victoza 0.6 milligrams (mg) subcutaneous pen injector 0.6 mg one time daily, Lantus Solostar U-100 Insulin 100 unit/milliliters (ml) pen 56 units subcutaneous one time per day, Lantus Solostar U-100 Insulin 100 unit/ml 68 units subcutaneous one time per day, Novolog U-100 Insulin aspart 100 unit/ml solution 20 units subcutaneous three times per day, Novolog U-100 Insulin aspart 100 unit/ml subcutaneous solution per Sliding Scale before meals and at bedtime VIAL ONLY NO FLEX PEN. Review of Medication Error Report dated 9/19/2022 indicated nurse pulled insulin from patient slot on cart. Patient hs two he receives and both insulin I slot side by side. Nurse spoke to patient about the insulin before administration of missing cap. Nurse than {sic} proceeded to administrate {sic} insulin by sliding scale. Immediately after injection resident states that only one of his insulins are in pen not both. Nurse noted that the fast-acting insulin belong to another resident that was in R#18 slot. Review of a Nurse's Note dated 9/19/2022 at 8:34 p.m. notated as Medication Error revealed R#18 had blood sugar check and results was for 6 units sliding scale coverage. LPN BB pulled all residents eye drops, medication, and insulins from his room slot on cart. LPN BB noted that flex pen for fast acting did not have a cover on it. LPN BB asked R#18 if he knew why his cover was missing off the pen. R#18 verbalized he was not sure. LPN BB informed resident that it was ok that cover just helps protect pen. LPN BB clicked the units of insulin for sliding scale at 26 units and administered to resident as he indicated to his right abdomen. Nurse disguarding {sic} the needle, and R#18 asked which insulin he took first, LPN BB stated his fast acting and resident stating that his fast acting was not a pen but a vial. Nurse checked the flex pen and noted that another resident's flex pen Novolin R was in R#18's slot. Nurse informed resident of the error and explained to resident that his vial was not in his slot but they both are fast acting insulin and there were not any contradicting issues of him receiving the Novolin R verse his Novolog. LPN BB explained to resident no cross contamination was at risk either since all needle tips are changed with each flex pen use and the needle is designed to prevent any back flow. LPN BB contacted physician to report the medication error. Further review of the medical record revealed a second Medication Error Report dated 2/8/2023 indicating Novolog given from another patients pen, not vial as ordered (validated it was a new pen of Novolog that was used). Nurse states she did not see residents' vial and saw the pen, so gave Novolog from pen-did not think it was a med error. Review of Nurse's Note dated 2/8/2023 at 12:46 p.m. indicated R#18 came to Administrator office and said the agency nurse gave him insulin from a pen at 6:00 a.m.-Physician notified-new orders received-follow-up with resident and reassured him he is safe. Interview on 2/14/2023 at 2:47 p.m. R#18 revealed that he was injected with the wrong insulin pen on two separate occasions. He stated the first time it happened was in September last year, and again this month (February). He stated the first incident the nurse placed his and another resident's insulin pen in the wrong place in the medication cart. The nurse picked it up and administered it to him without checking the name. Resident stated he was worried about cross contamination and requested a blood test to make sure he was not infected. He stated this happened a second time this month (February 2023) when an Agency nurse, who was unfamiliar with the medication cart, administered his morning insulin with an insulin pen. He stated he was trying to tell her to wait he doesn't get an insulin pen in the morning, that his morning insulin was in a vial, but before he could tell her she had already injected him with the insulin pen. He stated that the nurse informed him that the insulin was similar and there was not a chance of him getting a bloodborne pathogen. He stated the nurse told him she would file a report, since he was concerned about it. Resident stated that he followed up with the Administrator, and she told him that she was sorry that this happened again, and she would do training with the staff to make sure that it does not continue to happen. Resident stated the facility did training the first time it happened, yet it happened again, and this should not keep happening to him. Interview on 2/15/2023 at 1:10 p.m., the consultant pharmacist revealed that the facility did not make him aware of the medication errors with the insulin. He further stated that insulin pens should not be shared between residents. During further interview, he stated that he is not sure if there is a risk of any infections or blood borne pathogens with sharing insulin pens. Interview on 2/15/2023 at 2:38 p.m., the Medical Director revealed that he was notified of the medication errors involving the mix up of the insulin pens. He stated that if the same needles were not shared, there is little concern. Telephone interview on 2/15/2023 at 7:01 p.m., LPN BB revealed she works at the facility as needed (PRN) basis. She stated that she worked with R#18 prior to the incident with the insulin and was aware that she had to administer two different types of insulin based on his physician orders. She stated resident takes short acting and long-acting insulin. She stated she was talking with the resident about his medications as she was preparing the medications for administration. She stated that she pulled what she thought was his short acting insulin pen from his slotted medications in the med cart and administered the insulin to resident. She stated immediately as she administered the insulin, resident stated hey wait, what are you giving me, my short acting insulin is not a pen it is in a vial. LPN stated she looked at the insulin pen at this time and it did not have a label with resident's name. She further stated that the insulin pens come from the pharmacy in a bag with a label, and also a label on the cap. She stated the pen did not have a cap. She attested to not looking at the insulin closely enough before administering it to the resident. LPN BB stated that she should not have administered the medication if it did not have his name on it. She further stated that after auditing the medication cart, she found residents insulin vial in another resident's medication drawer and the nurse on the previous shift had not properly stored the insulins. Interview on 2/16/2023 at 9:13 a.m., DON revealed that nurses should have limited distractions when administering medications. She stated she contributes the medication errors to nurses being distracted during the medication pass. She stated that she had performed random medication rounds with the nurses and the certified medication aides (CMAs) and did not identify any issues. Interview on 2/16/2023 at 12:11 p.m., the Regional Nurse Consultant (RNC) revealed that she was aware of the February 2023 insulin administration error. She stated she advised the facility to find the root cause of the error and come up with a plan to keep things like this from happening. Interview on 2/16/2023 at 1:02 p.m., the Administrator revealed the new hire orientation has been revamped to ensure that the core competencies are completed prior to staff being able to work with residents independently. Review facility's education records revealed that licensed nurses and certified medication aides were re-educated on insulin administration and the 5 Rights of Medication Administration.

Based on observation, record review, and interviews, the facility failed to follow Physician Orders for one resident (R) (R#24) related to sliding scale insulin order to notify the physician for blood sugars greater than 401. The sample size was 33. Findings Include: Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including congested heart failure (CHF), chronic obstruction pulmonary disease (COPD), acute respiratory failure, diabetes mellitus, and restless leg syndrome. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Section N revealed resident received insulin injections seven days during the look back period. Review of the care plan dated 2/1/2023 revealed resident has diagnosis of diabetes mellitus with persistent elevation in fingerstick blood sugars (FSBS). Interventions to care include administer insulin and/or oral hypoglycemics as ordered and notify Physician as indicated. Review of the February Physician Orders revealed an order dated 8/24/2022 for Novolog Flex-pen 100 unit/milliliter (ml) sliding scale subcutaneous before meals: 0-59 = 0 units (call MD); 60-119 = 0 units; 120-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 301-350 = 9 units; 351-400 = 11 units; 401 or greater = 11 units (call MD). Review of the January 2023 Medication Administration Record (MAR) revealed on 1/26/2023 at 11:00 a.m., FSBS was 420 milligrams/deciliter (mg/dL) and on 1/30/2023 at 11:00 a.m., FSBS was 441 mg/dL. Review of the electronic medical record (EMR) revealed no evidence that the physician was notified of FSBS over 400 mg/dL, as ordered. Interview on 2/16/2023 at 1:58 p.m., the Director of Nursing verified there was no evidence in the EMR that physician was informed about elevated FSBS on 1/26/2034 and 1/30/2023. She stated it was an oversight, and reported that she had done an in-service on 2/3/2023 for the nurses and certified medication aides (CMAs) related to following physician orders for elevated blood sugars. Cross Refer F656

Based on observations, record review, resident and staff interviews, the facility failed to implement restorative nursing care for three residents (R) (R#35, R#43, R#70) as recommended post discharge from inpatient Rehabilitation Services. The sample size was 33 residents. Findings include: 1. Review of the clinical record revealed R#35 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA) with left hemiplegia, gastroesophageal reflux disease (GERD), and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit. Section G revealed resident was total dependent of two-persons for all activities of daily living (ADLs). She had functional limitations of upper and lower extremities on one side. Review of the care plan dated 1/1/2023 revealed the resident had limited mobility related hemiplegia and limited range of motion (ROM) to right side. Interventions to care include assist with ADL's as needed and refer to therapy as indicated, and see Restorative Plan. Review of the Physical Therapy Summary and Occupational Therapy Summary with service dates 11/9/2022 through 11/29/2022 revealed R#35 had met her maximum potential with a discharge disposition to Skilled Nursing Facility-Restorative Program. Restorative care to include ROM, transfers with Stand Aid, and exercise. Review of the list of residents on Restorative Nursing services revealed R#35 had start date for Restorative Nursing on 11/30/2022 for ROM to upper/lower body and transfers, but no evidence or documentation that Restorative Nursing services were provided. Interview on 2/16/2023 at 1:10 p.m., the Rehab Director stated R#35 reached her maximum potential and was discharged from therapy with referral to restorative nursing services. She stated R#35 was non-ambulatory but could stand with assistance. 2. Review of the clinical record revealed R#43 was admitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, need for assistance with personal care, and nicotine dependence. Review of the Admission MDS dated [DATE] revealed a BIMS score of 11, indicating mild cognitive impairment. Section G revealed resident required total dependence for all ADLs. He had functional limitations of upper extremities on both sides. Review of the care plan dated 1/19/2023 revealed the resident had limited mobility related to limited ROM to the shoulders bilaterally. Interventions to care include assist with ADL's as needed and refer to therapy as indicated. Review of the Physical Therapy Summary and Occupational Therapy Summary with service dates 1/5/2023 through 2/6/2023 revealed R#43 had met his maximum potential with a discharge disposition to Skilled Nursing Facility-Restorative Program. Restorative care to include ROM, ambulation, and exercise. Review of the list of residents on Restorative Nursing services revealed R#43 had start date for Restorative Nursing on 2/7/2023 for ROM to upper/lower body and walking, but no evidence or documentation that Restorative Nursing services were provided. Interview with the Rehab Director on 2/15/2023 at 1:10 p.m., stated R#43 was on caseload but had met maximum potential. She stated she referred him to Restorative Nursing for ROM to bilateral lower extremities and transfers with stand aid. Interview on 2/15/2023 at 11:00 a.m., the Director of Nursing (DON) stated the Restorative Nursing Program was in the process of being restarted and provided a list of residents who should be receiving Restorative Nursing services. 44960 3. Review of the clinical record revealed R#70 was readmitted to the facility on [DATE] with diagnoses of venous thrombosis, depression, aphasia, gastroesophageal reflux disease (GERD), apraxia, spastic hemiplegia affecting right dominant side, muscle weakness, history of falling, and unsteadiness of feet. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. Section G revealed resident required one-person physical assistance for ADLs and had limitations in range of motion (ROM) of her upper and lower extremities. Review of the care plan dated 2/2/2023 revealed the resident had limited mobility related to weakness and spastic hemiplegia affecting right side. Interventions to care include assist with ADLs as needed and refer to therapy as indicated. Review of the list of residents on Restorative Nursing services revealed R#70 had start date for Restorative Nursing on 11/10/2023 for ROM to upper/lower body and walking. The last documented date of service provided was 1/2/2023. Interview on 2/13/2023 at 11:53 a.m. with resident and her husband revealed she was admitted to the facility after a stroke and came here for therapy. Her husband stated that she is no longer on therapy services and that the staff does not walk with her or perform any exercises. He stated that the only exercises she gets now is when her husband walk with her with the walker. Interview on 2/14/2023 at 10:17 a.m. with R#70 with spouse at bedside, revealed she is not getting therapy. Her husband stated she is right-handed and her whole right side has weakness. He stated she needs some speech therapy. Interview on 2/16/2023 at 12:08 p.m. the Rehabilitation Director revealed they set up restorative program for all residents once they discharge from therapy, unless they refuse. She stated R#70 restorative plan is for ambulation 300 feet with weight bearing as tolerated with a hemi-walker, upper body range of motion, and lower body is active ROM for both legs.

Based on observations, record reviews, interviews, and review of the facility policy titled Fall Management, the facility failed to assure the safety of one resident (R#19) with a history of falls, by not placing resident in bed when she was asleep and leaning forward in wheelchair. The sample size is 33. Findings include: Review of the policy titled Fall Management reviewed 12/4/2021, indicates each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risks for falls. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's Disease, difficulty in walking, muscle weakness (generalized), need for assistance with personal care, osteoarthritis of knee, cramp and spasm, age-related osteoporosis without current pathological fracture. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section G indicated resident was total dependent of two-persons for transfers and limited assistance with walking. She had limitations in range of motion - Upper and Lower extremities - Impairment on both sides. Mobility Devices include wheelchair and walker. Balance During Transitions and Walking - Not steady only able to stabilize with human assistance. Review of the care plan updated 2/14/2023 indicated resident is a fall risk related to difficulty in walking, generalized muscle weakness, unsteadiness on feet and unsteady gait. The interventions listed includes assess contributing factors related to fall history, place patient in open area for maximum observation, place back to bed, and non-skid strips to both sides of bed. Review of the Progress Note dated 2/13/2023 at 10:00 a.m. that revealed Observed resident on floor in room. Resident stated she fell back asleep after I gave her morning meds and fell out of wheelchair. Noticed she had a cut approximately 1 cm long to top of head and she said she bumped it on her bedside table when she tried to get up. Small amount of blood washed out of hair and cut is no longer bleeding. Physician notified and advised to do neuro checks and keep an eye on the cut. Resident moved all extremities and assisted back into wheelchair. RP-son notified. Observation on 2/13/2023 at 12:30 p.m. revealed resident sitting in a wheelchair in the dining room eating lunch. Resident is moving the wheelchair back and forth while eating. The wheelchair's wheels are not locked. Observation on 2/14/2023 at 10:32 a.m. revealed resident out of bed to wheelchair in her room at the end of the hall. Resident has a walker positioned in front of her. Observation on 2/14/2023 at 12:11 p.m. revealed resident in her room at the end of the hall, sitting in her wheelchair. She was asleep and leaning forward in her wheelchair. During this observation, Housekeeper DD exited the room, looked at surveyor and stated, she is snoozing and has been since I have been in there cleaning. Housekeeper DD proceeded up the hall to clean other rooms on the hall. Observation on 2/14/2023 at 12:17 p.m., Licensed Practical Nurse (LPN) AA walked past R#19's room, looked in as she passed by, but did not enter the room. Observation on 2/14/2023 at 12:28 p.m. LPN AA entered residents' room, awakened her, asked if she was alright, and then administered her medications. LPN AA asked resident if she wanted to lay down, resident stated I don't care. LPN AA left the room. At this time surveyor asked LPN AA if she felt resident was safe sleeping in the wheelchair. LPA AA further stated that she is not sure why resident was left in the room at the end of the hall. She revealed that R#19 should not be left unattended in her room asleep in the wheelchair, because she is a high-risk for falls. She stated resident had a fell yesterday (2/13/2023). Interview on 2/14/2023 at 12:29 p.m. CNA CC revealed she saw resident at approximately 11:45 a.m. sitting in her room in the wheelchair sleepy and nodding off. CNA CC stated that she did not ask resident if she wanted to lie down for a nap or attempt to assist her to another area to be monitored because it just did not dawn on her to do that. CNA CC further stated that she is aware that resident is a high-risk for falls because her name is on the list that she has. Interview on 2/14/2023 at 12:55 p.m. with Director of Nursing Services (DNS) revealed her expectation is that if a resident with a history of falls is in a wheelchair asleep, that the staff should assist the resident to bed. She further stated residents that are high risk for falls be placed in a frequently observed area such as the nurse's station or dining room, to be monitored.

Based on observations, resident and staff interviews, and review of facility polices, the facility failed to ensure respiratory care was provided in accordance with standards of nursing practice for two of 13 residents (R) receiving oxygen therapy. Specifically, the facility failed to change the oxygen nasal cannula for R#37 and failed to administer oxygen at prescribed flow rate for R#51. Findings include: Review of the facility policy titled, Skilled Inpatient Services: Use of Oxygen Therapy reviewed 12/4/2021, revealed the intent is to ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. The nasal cannula should be changed every month and as needed. 1. Review of the clinical record revealed R#37 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and obstructive sleep apnea (OSA). Review of the Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the February Physician Orders revealed an order dated 1/12/2023 for oxygen via N/C at three lpm nasally every eight hours. Observation and interview on 2/13/2023 at 11:50 a.m. R#37 revealed the oxygen nasal cannula (N/C) was undated. The oxygen concentrator was set at three liters per minute (lpm) with the humidification bottle half full and undated. The resident stated the nasal cannula was the same one he came from the hospital with. Observations/interviews on 2/14/2023 at 10:43 a.m. and 2/15/2023 at 2:20 p.m., revealed N/C remained undated and resident stated no-one has changed the nasal cannula. Interview on 2/15/2023 at 8:52 a.m. Certified Nursing Assistant (CNA) GG stated he had been a CNA for over [AGE] years. He stated he usually works on the 100 Unit but was also responsible for changing out and/or cleaning the respiratory supplies throughout the facility, including changing out the oxygen nasal cannulas monthly. During further interview regarding R#37 report of using the same nasal cannula that he came from the hospital with, CNA GG replied that he did not know the resident was on oxygen. He stated it was an oversight. He further stated he assumed the responsibility for the respiratory supplies on 2/2/2023 and he now has access to residents receiving respiratory therapy, to track when supplies need to be changed. Interview on 2/16/2023 at 9:46 a.m., R#37 stated a man changed his nasal cannula last night and it felt much better. 46579 2. Review of the policy titled Skilled Inpatient Services: Use of Oxygen Therapy reviewed 12/4/2021, revealed that guidelines for use is that physician order for oxygen should be obtained and include the flow rate or percentage ordered; indicate if use should be continuous or as needed; method of oxygen delivery via nasal cannula, mask, etc. The care plan should reflect resident specific needs for oxygen as ordered. Review of the policy titled Skilled Inpatient Services-Patients Plan of Care dated 12/4/2021, revealed each resident will have a person-centered comprehensive care plan developed and implemented to meet the residents preferences and goals, and to address the residents medical, physical, mental, and psychosocial needs. Review of the clinical record revealed R#51 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, cerebral infarction, congested heart failure (CHF), COPD, and dementia. Review of the quarterly MDS dated [DATE], documented a BIMS score of 15, indicating no cognitive impairment. Review of the February Physician Orders revealed an order dated 3/27/2022 for oxygen via N/C at two lpm nasally every second shift. Review of care plan dated 12/31/2022, revealed resident has respiratory difficulties and risk for further decline related to COPD, respiratory failure, and history of bronchitis. Interventions to care include administer medications and treatments as ordered and oxygen at two liters as ordered. Review of the February 2023 electronic medication record (EMR) revealed staff were documenting every shift that oxygen was set at two liters via N/C. Observation on 2/13/2023 at 11:16 a.m., resident in bed with oxygen in use via N/C, and flow rate was set on one lpm. Observation on 2/14/2023 at 10:30 a.m. and 4:24 p.m., resident lying in bed with oxygen in use at one lpm, via N/C. Observation on 2/15/2023 at 11:35 a.m., resident lying in bed with oxygen at one lpm, via N/C. Observation and interview on 2/15/2023 at 12:05 p.m. with Licensed Practical Nurse (LPN) SS, verified the oxygen flow rate was set on one liter. She stated to surveyor is he ordered for two liters? Interview on 2/16/2023 at 11:45 a.m. revealed that nurses should be signing on the EMR after they have confirmed the oxygen rate is set as ordered.

Based on resident and staff interviews and review of facility policy titled Orientation, Training, and Competency, the facility failed to ensure staff was competent related to maintaining resident Bilevel Positive Airway Pressure (BiPAP) units used in the facility. The census was 75. Findings include: Review of the facility policy titled, Orientation, Training, and Competency reviewed 12/30/2022 revealed the intent of this center to establish an orientation plan, training schedule, and a defined set of competencies to promote well-trained associates for the position. Guideline: Competencies should be based on the center assessment Associates should complete competencies based on job duties and needs Education/training is provided routinely/covering various topics A record of learning for each associate will be maintained Organizational support may provide additional trainings through meetings, phone calls, emails, and webinars Review of CPAP [Continuous Positive Airway Pressure] Cleaning Instructions-How to properly clean your CPAP machine at https://comprehensivesleepcare.com/cpap-cleaning-instructions/ and CPAP Cleaning Instructions at www.mercyhme.com revealed the humidifier chamber should be washed in soapy water, rinsed well, and allowed to air dry. Interview on 2/15/2023 at 8:52 a.m. Certified Nursing Assistant (CNA) GG stated he had been a CNA for over [AGE] years. He stated he usually worked the 3-11 and 11-7 shifts as double shifts on 12-day stretches then off for two days. He stated he usually works on the 100 Unit but was also responsible for changing out and cleaning the respiratory supplies throughout the facility as follows: 1. Weekly (Wednesday nights): wash out the PAP humidifier chamber with soap and water and dries it with a dry wipe. He stated that's the way he's always done it. 2. Every three months: change out PAP humidifier chambers. He stated he recently found out he could order replacement PAP humidifier chambers. During continued interview, he stated he did not receive any formal inservice training for these responsibilities but relied on his experience as a CNA and verbal recommendations from the Corporate Respiratory Therapy Consultant (CRTC). Interview on 2/16/2023 at 4:45 p.m., the Administrator stated she was unaware that CNA GG did not receive inservice training from the Respiratory Consultant.

Based on observations, record review and staff interviews, the facility failed to ensure that all items on the kitchen tray line, specially ground pork, were held at the appropriate temperature to prevent food born illness which effected 20 residents who received ground meats. Findings include: Review of policies entitled, Food Preparation and Distribution, updated (MONTH) 2019 revealed that a temperature monitoring log will be maintained throughout meal service hot foods will be held at greater or equal to 135 degrees Farenheit (F), cold foods will be held at less or equal to 41 degrees F, while frequently monitoring temperatures during meal service, if any temperature is determined to be out of ranger, corrective action will take place (hot items will be pulled from the tray line and re-heated until an internal temperature of 165 degree F for 15 seconds is reached; cold items will be pulled from the tray line and placed into an ice bath, cooler, freezer, or blast chiller until 41 degrees or lower is reached; and items will be re-checked and proper temperature verified before beginning to serve. Observation and interview of the main kitchen tray line temperature taken by Food Service Aide (FSA) AA with the facilities calibrated thermometer on 1/23/20 between 6:24 p.m. through 6:39 p.m., revealed that the ground pork had a temperature of 130 degrees F. Interview with FSA AA at this time revealed that he was unsure how many ground pork have been served so far. An interview with Dietary Manager on 1/24/20 at 12:51 p.m. revealed the facility has in-services monthly, and she expects that staff identify when temps are not correct and pull food and not serve any food at a temperature that is too low or too high.

Based on observation, record review, and staff interview, the facility failed to ensure that medications were stored at the proper temperature in two of two medication room refrigerators, and failed to ensure that needles used to deliver intramuscular injections were discarded after the manufacturer's expiration date in one of two medication rooms. The facility census was 95, and the sample size was 34 residents. Findings include: During observation in the Station 1 med room on 8/9/18 at 11:00 a.m., one box of 25-gauge 1-inch needles, and one box of 21-gauge 1-inch needles were observed with a manufacturer's expiration date of 12-2017 printed on the box. This was verified during interview with Licensed Practical Nurse (LPN) CC at this time, who stated that Central Supply staff stocked and checked the supplies in the medication rooms. During observation in the medication cart 2 with LPN BB on 8/9/18 at 11:10 a.m., she stated that there was a total of nine 25-gauge needles in the cart with an expiration date of 12-2017, but was not aware of any residents on her hall that received injections with this type of needle. During observation in medication cart 1 with Registered Nurse (RN) EE on 8/9/18 at 11:20 a.m. revealed that there was seven 25-gauge and six 21-gauge needles with an expiration date on the packaging of 12-2017. During interview with RN EE at this time, she stated that the night shift nurses gave vitamin B-12 injections to four residents, and that the nurses would use these needles for the injections. During interview with Central Supply staff DD on 8/9/18 at 11:29 a.m., she stated that she had not ordered any needles since the facility was bought by a different company in 2014, and had not checked the needle boxes for expiration dates. During observations in the Station 1 medication room on 8/9/18 at 2:20 p.m., the medication refrigerator temperature was 30 degrees (Fahrenheit) as measured by the facility's thermometer inside the refrigerator, and this was verified by LPN BB at this time. Review of the (MONTH) Med Room Refrigerator Temp Log for Hall 1 revealed that the temperature was recorded as 38 or 39 degrees each day. Further review of the log revealed that the refrigerator temperature should be maintained ranging between 36 and 46 degrees. Inside this refrigerator the following medications were observed: One vial of unopened [MEDICATION NAME] N insulin One vial of unopened Humalog insulin One vial of unopened [MEDICATION NAME] insulin One vial of unopened [MEDICATION NAME] R insulin Two Tresiba insulin pens 29 Dronabinol 2.5 mg (milligram) tablets in blister packs One [MEDICATION NAME][MEDICATION NAME] injection Two [MEDICATION NAME] 2 mg vials Five 1 ml single dose vials of [MEDICAL CONDITION] vaccine Two ten-dose vials of [MEDICATION NAME] PPD (purified protein derivative), one opened and one unopened Inside an e-box (emergency box) were four [MEDICATION NAME] 1-ml (milliliter) vials 12 [MEDICATION NAME] suppositories 1 Toujeo Solo Star 1.5 ml insulin pen Inside another e-box was one vial Humalog insulin; one vial of [MEDICATION NAME] insulin; one vial of [MEDICATION NAME] 70/30 insulin; 1 vial of [MEDICATION NAME] Solo Star insulin; one [MEDICATION NAME] flextouch insulin pen; and six [MEDICATION NAME] 25 mg suppositories. These observations were verified by LPN BB at this time. During observation in the Station 3 medication room on 8/9/18 at 2:33 p.m., the medication refrigerator temperature was observed to be 29 degrees (Fahrenheit) as measured with the facility's thermometer inside the refrigerator. This was verified during interview with RN GG at this time. Review of the Med Room Refrigerator Temp Log for Hall 3 for the month of (MONTH) revealed that the temperature ranged between 26 degrees and 30 degrees the entire month. Review of the (MONTH) Temperature Log revealed that the temperature was below 36 degrees five of the nine days recorded. Further review of this Log revealed the following notation: If temp is outside range please indicate what you did to correct it in comments section and recheck temperature in one hour and record results under comments. Continued review of the (MONTH) and (MONTH) Temp Logs revealed that no comments had been written in on either form. Inside this refrigerator the following medications were observed: One unopened vial of [MEDICATION NAME] R insulin Three 10-test vials of [MEDICATION NAME] PPD Two Trulicity insulin pens 22 [MEDICATION NAME] 25 mg suppositories Four [MEDICATION NAME] ([MEDICATION NAME] PPD) 10-test vials Four [MEDICATION NAME] 650 mg suppositories Four Tresiba insulin pens One Toujeo [MEDICATION NAME]pen Inside an e-box was one unopened vial each of Humalog, [MEDICATION NAME], and [MEDICATION NAME] 70/30; a [MEDICATION NAME]pen; a [MEDICATION NAME] Flextouch pen; and six [MEDICATION NAME] 25 mg suppositories. Inside another e-box were four [MEDICATION NAME] 1 ml vials These observations were verified by LPN FF at this time. During interview with the Administrator on 8/9/18 at 2:40 p.m., she stated that the medication room refrigerator temperatures should be whatever was directed on the Temp Log forms, so that it should be between 36 and 46 degrees. Review of the facility's Medication Storage in the Care Center policy with a reviewed and updated date of (MONTH) (YEAR) revealed: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 2 degrees C (Centigrade) (36 degrees F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. The temperature of the med room refrigerators must be checked daily and documented on a Refrigerator Temperature Log. If vaccines are stored in the refrigerator, temperatures must be checked and documented twice daily. The temperature should be between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F). This log should be kept on or near the refrigerator in the med room. When the temperature of the refrigerator is not within the proper range (between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F), document the temperature and immediately notify the supervisor and/or Director of Nursing for further instruction and document the corrective action taken. Evaluation of handling of the medications in the refrigerator will be needed. Contact the pharmacy for instructions on handling.

Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in five resident rooms (rooms 136, 138, 303, 316, 317) on two of three halls and common dining areas in three of three dining rooms (dining rooms #1, #2, #3) and unit 100 hallways. The census was 95. Findings include: 1. Observation in room [ROOM NUMBER] on 8/7/18 at 8:44 a.m. revealed the following: -There were two continuous black scrapes on the wall 9-inches apart from below the television on the wall to the nightlight below it, all along the length of the wall going toward the hallway. -There was a triangular-shaped missing piece of laminate on the B-bed closet door at the bottom left side exposing the particle board underneath, and a 4-inch by 0.25-inch missing piece of laminate on the vertical aspect of the front of the dresser top in front of the mirror. Observation in room [ROOM NUMBER] on 8/7/18 at 8:56 a.m. revealed the following: -There was a 14-inch long by 7-1/2-inch wide section of sheet rock that had been plastered over but not painted across from the A-bed. -There were two holes in the wall, one above the other, 3/4-inch in circumference above the cork bulletin board across from the A-bed. -There was a 2-inch by 2-inch triangular-shaped hole in the wall to the left of the bathroom door above the baseboard. -There was a deep horizontal gouge in the wall 25 inches above the baseboard to the left of the bathroom door. These concerns were verified by the Maintenance Supervisor during a walk-through of the environment on 8/9/18 at 10:12 a.m. In addition to the above concerns, he verified that the laminate was missing off the third (bottom) drawer of the cabinet in the bathroom in room [ROOM NUMBER]. 2. Observation on 8/6/18 at 10:46 a.m., revealed room [ROOM NUMBER] had four patches of torn sheet rock above head of bed A, approximately two inches long; one ceiling tile above bed A with a one inch hole in corner; large circular patch of gouged, uneven sheet rock, approximately four inches in diameter, at head of bed B; four small holes, approximately size of nickels, on wall above television stand. Observation on 8/6/18 at 10:50 a.m., revealed room [ROOM NUMBER] had dusty window blinds and dusty air conditioner(AC) face grill/plate; Four small holes, approximately size of nickels, on wall above where television sitting on countertop. Observation on 8/6/18 at 1:44 p.m., revealed room [ROOM NUMBER] had dusty window blinds and dusty AC face grill/plate. Observation on 8/7/18 at 9:30 a.m., revealed room [ROOM NUMBER] had six small holes, approximately size of nickels, on the wall above where television is mounted on wall; cloth chair in bathroom with dark brown stains in chair cushion; night stand drawers broken from track; drawer in bathroom missing laminate covering from front drawer. Observation on 8/6/18 at 10:23 a.m., revealed dining room [ROOM NUMBER] had two patches of wallpaper strips missing on two separate walls, missing baseboards on three separate walls, one wall had approximately six inch cut/gouge in sheet rock and wallpaper and dusty blinds and window sills with cob webs and debris in corners of all windows in dining room. Observation on 8/6/18 at 11:04 a.m., revealed dining room [ROOM NUMBER] had dusty base boards and dusty blinds and window sills with cob webs and debris in corners of nine windows. Observation on 8/6/18 at 11:08 a.m., revealed dining room [ROOM NUMBER] had missing baseboards on two walls, missing strip of wall paper on one wall and peeling wallpaper beside break room, dusty blinds and window sills with cob webs and debris in corner of 19 windows. Observation on 8/6/18 at 10:37 a.m., revealed on 100 hall, two areas of patched sheet rock on walls above secured fire extinguisher cabinets. Interview on 8/8/18 at 10:36 a.m., with Laundry Aide LL stated that she and one other housekeeping aide split the rooms on the 100 hall. She stated that she sweeps, mops, damp dusts all the furniture and equipment in the residents rooms. She also wipes the blinds and air conditioner units daily. She further stated she also cleans the bathrooms, wipes down the walls, empties the trash and restocks supplies (soap and gloves). She further stated that she cleans the dining rooms after meals, wipes the tables down, changes the table clothes. She cleans the blinds and window sills every two weeks in the community dining areas. Interview on 8/9/18 at 10:10 a.m., with Maintenance Supervisor, stated that staff put work orders into computer system, and he sorts them according to priority and distributes assignments to the two maintenance staff. They work on work orders, plus perform general maintenance for facility, such a checking emergency exits, checking call lights and water temperatures, side rails, cleaning AC coils, changing AC filters and checking emergency doors. During walking rounds, Maintenance Supervisor verified environmental concerns identified during survey. Interview on 8/9/18 at 10:39 a.m., with Housekeeping Supervisor, stated that the housekeeping staff are trained and educated on their job responsibilities, including daily resident room cleaning of all furniture, hard surface areas, bathrooms, toilets, wipe down the walls, dust the window blinds and AC units and wipe the over bed table. She further stated they are also supposed to sweep and mop each room daily. She further stated that the staff are assigned to clean the offices, public restrooms and the dining rooms after meals. She stated that they are to be wiping the blinds and window sills in the dining rooms once per week, but could not give a specific day or shift it is done, just once per week. She stated that there is not a checklist of duties for staff to use for tasks needed to be done. She stated they just know they need to do it. She stated she does not perform spot checks to ensure tasks are being completed on a daily basis. She verified during a walk through the environmental concerns identified during the survey.

Based on record review, review of the facility's Medication Discrepancy/Errors Guideline and staff interview, it was determined that the facility failed to notify the physician and responsible party that a Licensed Practical Nurse (LPN) had administered an incorrect dose of [MEDICATION NAME] to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/16, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that the medication error should be reported to the Director of Nursing (DON) or acting supervisor immediately and the physician promptly. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her fasting blood sugar level (FSBS) was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. She was discharged back to the facility on [DATE]. Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, had inaccurately administered 100 units of [MEDICATION NAME] to R10 instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m.and that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 and that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m. There was no indication that the family was notified of the medication error at that time. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/23/16 at 11:20 a.m. with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review, review of the facility's Orientation Policy, review of the facility's Medication Discrepancies/Errors Procedural Guidelines, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered Insulin correctly and safely to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Orientation Period policy revealed that the first three (3) calendar months of employment was considered an orientation period for newly hired employees. Continued review revealed that During this time the associate's job performance should be observed by the supervisor. Review of the facility's Medication Discrepancy/Errors Procedural Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the National Council of State Boards of Nursing, Chapter 410-10-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.G.A. §§ 43-1-25, 43-26-2, 43-26-3, 43-26-5, 43-26-32, and 43-26-42 documented that Licensed Practical Nurses (LPNs) may participate in the assessment, planning, implementation and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. The facility failed to ensure that a new licensed nurse orientee administered the correct dose of [MEDICATION NAME] to R10 on 8/31/16 at 9:00 p.m. which resulted in the resident's hospitalization for [DIAGNOSES REDACTED] (low blood sugar level) on 9/1/16. (Cross refer to F333) There was no indication that licensed nursing staff identified that the [MEDICATION NAME] was a long-acting Insulin that may have required monitoring of blood sugar levels after 4:00 p.m. and the probable need to hold all subsequent Insulin administration. (Cross refer to F333) Although licensed nursing staff had obtained the resident's blood sugar levels on 8/31/16 at 11:00 p.m. (122) and on 9/1/16 at 1:30 a.m. (217), 2:45 a.m. (277), 11:00 a.m. (49) and 4:00 p.m. (70), there was no indication that staff were monitoring the resident closely for twenty-four (24) hours after the incident per facility policy. (Cross refer to F333) The facility failed to ensure that licensed nursing staff notified the Physician and Director of Nursing (DON) immediately of the significant medication error per facility policy until twenty-four (24) hours later. (Cross refer to F157) There was no indication that staff notified the Physician/NP of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. or the interventions staff implemented to increase the blood sugar level at that time. There was no indication that the family was notified timely of the significant medication error until after the resident was sent to the hospital on [DATE] at 11:00 p.m. (Cross refer to F157) Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. (cross refer to F333) review of the resident's medical record revealed [REDACTED]. (Cross refer to F333) Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review and interview, it was determined that the facility failed to follow the care plan to administer insulin as ordered by the physician for one (1) Resident (R) (R10) of six (6) residents reviewed for insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Cross refer to F333) Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that LPN CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician and as care planned on 8/31/16 at 9:00 p.m. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on observation, record review and interview, it was determined that the facility failed to ensure that one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin was free of a significant medication error from a sample of sixteen (16) residents. This failure resulted in harm for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer Insulin as ordered. review of the resident's medical record revealed [REDACTED]. [REDACTED]. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Continued review revealed that the resident received 1/2 amp of [MEDICATION NAME] (D) 50 and that her blood sugar level was currently 208. Further review revealed that her vital signs were stable and she was alert. Review of the hospital physician progress notes [REDACTED]. Continued review revealed that the resident's blood sugar levels stabilized and she was moved to the Medical/Surgical floor by 9/4/16. She was discharged back to the facility on [DATE]. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident's caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., twenty-four (24) hours after she had incorrectly administered 100 units of [MEDICATION NAME] to the resident and two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. Further interview revealed that she instructed the Certified Nursing Assistants (CNAs) to transfer the resident to the wheelchair, place her at EE's medication cart so that LPN EE could monitor her closely and LPN EE gave her Med Pass to drink. Continued interview revealed that the resident was alert and without symptoms of [DIAGNOSES REDACTED] when LPN EE left the facility at 11:00 p.m. Continued interview with LPN EE revealed that she notified the on-coming nurse LPN FF who worked 11:00 p.m. to 7:00 a.m. about the incident and instructed LPN FF to continue to monitor the resident. Interview on 9/22/16 at 1:55 p.m. with LPN GG via telephone revealed that she had observed LPN CC draw up the correct amount of [MEDICATION NAME] (12 units) and administer it to R#10 on 9/1/16 at 9:00 p.m. two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 4:00 p.m. with the Consultant Pharmacist via telephone revealed that he was unaware that nursing staff had administered 100 units of [MEDICATION NAME] instead of 12 units as ordered to R#10 on 8/31/16. Continued interview with the Consultant Pharmacist revealed that [MEDICATION NAME] was a long-acting Insulin and that the resident could possibly have abnormally low blood sugar levels up to twenty-six (26) hours after administration of such a high dose, especially if she was not eating well and nursing staff continued to administer Insulin. Further interview revealed that he expected nursing staff to hold the 6 units [MEDICATION NAME] R Insulin at 7:00 a.m. and the 12 units of [MEDICATION NAME] at 9:00 p.m. on 9/1/16. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/22/16 at 5:40 p.m. with the Nurse Practitioner (NP) via telephone revealed that she was in the facility on 9/1/16 but, that she was unaware that the resident had received the incorrect dose of [MEDICATION NAME] the night before on 8/31/16 at 9:00 p.m. until after the resident was hospitalized . Continued interview revealed that she had not been notified by staff of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. Further interview revealed that if nursing staff had notified her of the medication error from the previous night she would have notified the physician. Continued interview revealed that she would expect nursing staff to hold the 6 units of [MEDICATION NAME] R insulin at 7:00 a.m. Further interview revealed that the resident's blood sugar levels fluctuated but, she could not remember if the levels had ever been as low as 27 without reviewing the resident's medical record. Interview with LPN EE on 9/23/16 at 11:20 a.m. revealed that she and LPN CC, the new orientee, were the only nurses working on Unit II on 8/31/16 between 7:00 p.m. and 11:00 p.m. Continued interview revealed that she also needed to administer medications at that time and that CC told her she felt confident that she could administer the insulin. Continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven (7) rooms without problems; however, she did not observe LPN CC administer Insulin to those residents at that time. Further interview with LPN EE revealed that she had never observed LPN CC administer Insulin to any resident. LPN EE stated that LPN CC was a licensed nurse and should have been able to administer Insulin correctly. Continued interview with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Further interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interview on 9/23/16 at 1:23 p.m. with LPN FF, an agency nurse, via phone revealed that she worked 8/31/16 from 11:00 p.m. to 7:00 a.m. and took over the medication cart from LPN EE at 11:00 p.m. Continued interview revealed that she was not notified that LPN CC had administered an incorrect dose of insulin to R#10 at 9:00 p.m. and therefore, did not notify the physician of the error. Further interview revealed that she did not observe LPN CC administer any medications on her shift because she was an agency nurse and did not orient other nurses. Observation of R10 on 9/23/16 at 12:35 p.m. revealed that she was alert with confusion and without symptoms of [DIAGNOSES REDACTED]. She stated at that time that she was happy to be home. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. (100% as of 11/7/16) 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. (100% nurses were inserviced by 11/7/16) 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. (LPN no longer employeed at facility-she resigned) 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review and interview, it was determined that the facility failed to ensure that the clinical record for one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration was complete and accurately documented from a sample of sixteen (16)residents. The facility failed to ensure that a factual description of the medication error and the on-going monitoring of the condition for 24 to 72 hours was accurately and completely documented in the medical record as per facility policy for R10. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R#10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident ' s caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., two hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked 7:00 p.m. to 11:00 p.m. on 8/31/16 when LPN CC administered 100 units of [MEDICATION NAME] to R10. Continued interview revealed that CC notified her of the medication error and that the resident was placed in a wheelchair by her medication cart, given Med Pass to drink and monitored closely. Further interview revealed that she notified the on-coming nurse FF at 11:00 p.m. to continue monitoring the resident. However, there was no indication that staff on subsequent shifts had been notified about the significant medication error. Interview with LPN EE again on 9/23/16 at 11:20 a.m. revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document any change in a resident's status or condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review, review of the facility's Medication Discrepancy/Errors Guideline and staff interview, it was determined that the facility failed to notify the physician and responsible party that a Licensed Practical Nurse (LPN) had administered an incorrect dose of [MEDICATION NAME] to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/16, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that the medication error should be reported to the Director of Nursing (DON) or acting supervisor immediately and the physician promptly. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her fasting blood sugar level (FSBS) was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. She was discharged back to the facility on [DATE]. Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, had inaccurately administered 100 units of [MEDICATION NAME] to R10 instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m.and that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 and that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m. There was no indication that the family was notified of the medication error at that time. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/23/16 at 11:20 a.m. with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review, review of the facility's Orientation Policy, review of the facility's Medication Discrepancies/Errors Procedural Guidelines, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered Insulin correctly and safely to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Orientation Period policy revealed that the first three (3) calendar months of employment was considered an orientation period for newly hired employees. Continued review revealed that During this time the associate's job performance should be observed by the supervisor. Review of the facility's Medication Discrepancy/Errors Procedural Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the National Council of State Boards of Nursing, Chapter 410-10-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.G.A. §§ 43-1-25, 43-26-2, 43-26-3, 43-26-5, 43-26-32, and 43-26-42 documented that Licensed Practical Nurses (LPNs) may participate in the assessment, planning, implementation and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. The facility failed to ensure that a new licensed nurse orientee administered the correct dose of [MEDICATION NAME] to R10 on 8/31/16 at 9:00 p.m. which resulted in the resident's hospitalization for [DIAGNOSES REDACTED] (low blood sugar level) on 9/1/16. (Cross refer to F333) There was no indication that licensed nursing staff identified that the [MEDICATION NAME] was a long-acting Insulin that may have required monitoring of blood sugar levels after 4:00 p.m. and the probable need to hold all subsequent Insulin administration. (Cross refer to F333) Although licensed nursing staff had obtained the resident's blood sugar levels on 8/31/16 at 11:00 p.m. (122) and on 9/1/16 at 1:30 a.m. (217), 2:45 a.m. (277), 11:00 a.m. (49) and 4:00 p.m. (70), there was no indication that staff were monitoring the resident closely for twenty-four (24) hours after the incident per facility policy. (Cross refer to F333) The facility failed to ensure that licensed nursing staff notified the Physician and Director of Nursing (DON) immediately of the significant medication error per facility policy until twenty-four (24) hours later. (Cross refer to F157) There was no indication that staff notified the Physician/NP of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. or the interventions staff implemented to increase the blood sugar level at that time. There was no indication that the family was notified timely of the significant medication error until after the resident was sent to the hospital on [DATE] at 11:00 p.m. (Cross refer to F157) Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. (cross refer to F333) review of the resident's medical record revealed [REDACTED]. (Cross refer to F333) Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review and interview, it was determined that the facility failed to follow the care plan to administer insulin as ordered by the physician for one (1) Resident (R) (R10) of six (6) residents reviewed for insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Cross refer to F333) Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that LPN CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician and as care planned on 8/31/16 at 9:00 p.m. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on observation, record review and interview, it was determined that the facility failed to ensure that one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin was free of a significant medication error from a sample of sixteen (16) residents. This failure resulted in harm for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer Insulin as ordered. review of the resident's medical record revealed [REDACTED]. [REDACTED]. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Continued review revealed that the resident received 1/2 amp of [MEDICATION NAME] (D) 50 and that her blood sugar level was currently 208. Further review revealed that her vital signs were stable and she was alert. Review of the hospital physician progress notes [REDACTED]. Continued review revealed that the resident's blood sugar levels stabilized and she was moved to the Medical/Surgical floor by 9/4/16. She was discharged back to the facility on [DATE]. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident's caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., twenty-four (24) hours after she had incorrectly administered 100 units of [MEDICATION NAME] to the resident and two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. Further interview revealed that she instructed the Certified Nursing Assistants (CNAs) to transfer the resident to the wheelchair, place her at EE's medication cart so that LPN EE could monitor her closely and LPN EE gave her Med Pass to drink. Continued interview revealed that the resident was alert and without symptoms of [DIAGNOSES REDACTED] when LPN EE left the facility at 11:00 p.m. Continued interview with LPN EE revealed that she notified the on-coming nurse LPN FF who worked 11:00 p.m. to 7:00 a.m. about the incident and instructed LPN FF to continue to monitor the resident. Interview on 9/22/16 at 1:55 p.m. with LPN GG via telephone revealed that she had observed LPN CC draw up the correct amount of [MEDICATION NAME] (12 units) and administer it to R#10 on 9/1/16 at 9:00 p.m. two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 4:00 p.m. with the Consultant Pharmacist via telephone revealed that he was unaware that nursing staff had administered 100 units of [MEDICATION NAME] instead of 12 units as ordered to R#10 on 8/31/16. Continued interview with the Consultant Pharmacist revealed that [MEDICATION NAME] was a long-acting Insulin and that the resident could possibly have abnormally low blood sugar levels up to twenty-six (26) hours after administration of such a high dose, especially if she was not eating well and nursing staff continued to administer Insulin. Further interview revealed that he expected nursing staff to hold the 6 units [MEDICATION NAME] R Insulin at 7:00 a.m. and the 12 units of [MEDICATION NAME] at 9:00 p.m. on 9/1/16. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/22/16 at 5:40 p.m. with the Nurse Practitioner (NP) via telephone revealed that she was in the facility on 9/1/16 but, that she was unaware that the resident had received the incorrect dose of [MEDICATION NAME] the night before on 8/31/16 at 9:00 p.m. until after the resident was hospitalized . Continued interview revealed that she had not been notified by staff of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. Further interview revealed that if nursing staff had notified her of the medication error from the previous night she would have notified the physician. Continued interview revealed that she would expect nursing staff to hold the 6 units of [MEDICATION NAME] R insulin at 7:00 a.m. Further interview revealed that the resident's blood sugar levels fluctuated but, she could not remember if the levels had ever been as low as 27 without reviewing the resident's medical record. Interview with LPN EE on 9/23/16 at 11:20 a.m. revealed that she and LPN CC, the new orientee, were the only nurses working on Unit II on 8/31/16 between 7:00 p.m. and 11:00 p.m. Continued interview revealed that she also needed to administer medications at that time and that CC told her she felt confident that she could administer the insulin. Continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven (7) rooms without problems; however, she did not observe LPN CC administer Insulin to those residents at that time. Further interview with LPN EE revealed that she had never observed LPN CC administer Insulin to any resident. LPN EE stated that LPN CC was a licensed nurse and should have been able to administer Insulin correctly. Continued interview with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Further interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interview on 9/23/16 at 1:23 p.m. with LPN FF, an agency nurse, via phone revealed that she worked 8/31/16 from 11:00 p.m. to 7:00 a.m. and took over the medication cart from LPN EE at 11:00 p.m. Continued interview revealed that she was not notified that LPN CC had administered an incorrect dose of insulin to R#10 at 9:00 p.m. and therefore, did not notify the physician of the error. Further interview revealed that she did not observe LPN CC administer any medications on her shift because she was an agency nurse and did not orient other nurses. Observation of R10 on 9/23/16 at 12:35 p.m. revealed that she was alert with confusion and without symptoms of [DIAGNOSES REDACTED]. She stated at that time that she was happy to be home. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. (100% as of 11/7/16) 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. (100% nurses were inserviced by 11/7/16) 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. (LPN no longer employeed at facility-she resigned) 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review and interview, it was determined that the facility failed to ensure that the clinical record for one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration was complete and accurately documented from a sample of sixteen (16)residents. The facility failed to ensure that a factual description of the medication error and the on-going monitoring of the condition for 24 to 72 hours was accurately and completely documented in the medical record as per facility policy for R10. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R#10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident ' s caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., two hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked 7:00 p.m. to 11:00 p.m. on 8/31/16 when LPN CC administered 100 units of [MEDICATION NAME] to R10. Continued interview revealed that CC notified her of the medication error and that the resident was placed in a wheelchair by her medication cart, given Med Pass to drink and monitored closely. Further interview revealed that she notified the on-coming nurse FF at 11:00 p.m. to continue monitoring the resident. However, there was no indication that staff on subsequent shifts had been notified about the significant medication error. Interview with LPN EE again on 9/23/16 at 11:20 a.m. revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document any change in a resident's status or condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review, review of the facility's Medication Discrepancy/Errors Guideline and staff interview, it was determined that the facility failed to notify the physician and responsible party that a Licensed Practical Nurse (LPN) had administered an incorrect dose of [MEDICATION NAME] to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/16, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that the medication error should be reported to the Director of Nursing (DON) or acting supervisor immediately and the physician promptly. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her fasting blood sugar level (FSBS) was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. She was discharged back to the facility on [DATE]. Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, had inaccurately administered 100 units of [MEDICATION NAME] to R10 instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m.and that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 and that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m. There was no indication that the family was notified of the medication error at that time. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/23/16 at 11:20 a.m. with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review, review of the facility's Orientation Policy, review of the facility's Medication Discrepancies/Errors Procedural Guidelines, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered Insulin correctly and safely to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Orientation Period policy revealed that the first three (3) calendar months of employment was considered an orientation period for newly hired employees. Continued review revealed that During this time the associate's job performance should be observed by the supervisor. Review of the facility's Medication Discrepancy/Errors Procedural Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the National Council of State Boards of Nursing, Chapter 410-10-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.G.A. §§ 43-1-25, 43-26-2, 43-26-3, 43-26-5, 43-26-32, and 43-26-42 documented that Licensed Practical Nurses (LPNs) may participate in the assessment, planning, implementation and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. The facility failed to ensure that a new licensed nurse orientee administered the correct dose of [MEDICATION NAME] to R10 on 8/31/16 at 9:00 p.m. which resulted in the resident's hospitalization for [DIAGNOSES REDACTED] (low blood sugar level) on 9/1/16. (Cross refer to F333) There was no indication that licensed nursing staff identified that the [MEDICATION NAME] was a long-acting Insulin that may have required monitoring of blood sugar levels after 4:00 p.m. and the probable need to hold all subsequent Insulin administration. (Cross refer to F333) Although licensed nursing staff had obtained the resident's blood sugar levels on 8/31/16 at 11:00 p.m. (122) and on 9/1/16 at 1:30 a.m. (217), 2:45 a.m. (277), 11:00 a.m. (49) and 4:00 p.m. (70), there was no indication that staff were monitoring the resident closely for twenty-four (24) hours after the incident per facility policy. (Cross refer to F333) The facility failed to ensure that licensed nursing staff notified the Physician and Director of Nursing (DON) immediately of the significant medication error per facility policy until twenty-four (24) hours later. (Cross refer to F157) There was no indication that staff notified the Physician/NP of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. or the interventions staff implemented to increase the blood sugar level at that time. There was no indication that the family was notified timely of the significant medication error until after the resident was sent to the hospital on [DATE] at 11:00 p.m. (Cross refer to F157) Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. (cross refer to F333) review of the resident's medical record revealed [REDACTED]. (Cross refer to F333) Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review, policy and procedure review and interviews, the facility failed to follow the care plan interventions related to the physician's regimen of care for three (3) of three (3) sampled residents with pressure ulcers out of thirty one (31) residents that received wound care treatment. (Resident #1, 2 and 3). Refer F314 Findings include: Review of the policy titled Patient's Plan of Care documented: It is the intent of this center to develop and maintain an individualized plan of care for each. An interdisciplinary team, in co-ordination with other patient care services, develops and maintains a care plan for each resident. The care plan is developed from the patient assessment (MDS) and in coordination with the with the attending physician's regimen of care. The care plan is available for use by all personnel care/services to/for the patient. It includes, but not limited to: incorporate identified problem areas, incorporate risk facto (s) associated with the identified problem (s), reflect treatment goals and objectives in measurable goals. 1. Record Review for Resident #1 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was at risk for pressure ulcers but did not have any pressure ulcers of Stage I or higher at that time. The Care Area Assessment (CAA) triggered Pressure Ulcer with the decision to be care planned. Review of the Significant Change MDS assessment dated [DATE] indicated the resident had one (1) unstageable pressure ulcer. Review of an Acute Care Plan for Resident #1 dated 6/16/16 identified an unstageable pressure ulcer to the left heel with an intervention that included but not limited to; Provide treatment per algorithm as ordered. Review of the physician's orders [REDACTED]. On 5/17/16 the order for treatment was changed to daily (QD) and as needed (PRN). Review of the Treatment Administration Record (TAR) From May through July 2016 for Resident #1 revealed no evidence that the wound care treatment was administered to the left heel, as prescribed by the physician, for a total of thirty one (31) times. 2. Record review for Resident #2 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated the resident had two (2) Stage II pressure Ulcers with one (1) on admission and one (1) Stage IV pressure ulcer on admission. The CAA triggered Pressure Ulcers with the decision to be care planned. Review of the Care Plan initiated on 7/16/15 for Resident #2 identified the resident has pressure ulcers and is at risk for additional pressure ulcers. There is no documentation that reflects any of the multiple wounds that Resident #2 has or an intervention to reflect the physician's regimen of care, however, an Acute Care Plan dated 7/7/15 identified a Stage IV pressure ulcer to the sacrum, Stage II to the left buttock and a Stage II to the left lateral foot. The interventions included, but not limited to: Provide treatment per algorithm. Review of the Physician order [REDACTED]. An order dated 12/7/16 for treatment to a Stage II pressure ulcer of the Sacral Coccygeal daily (QD) and PRN. An order dated 1/15/16 for treatment to a wound of the right groin/scrotal area daily (QD) and PRN. An order on 4/23/16 for treatment to a Stage II wound of the right posterior leg (thigh) daily (QD) and PRN. Review of the TAR from May through July 2016 for Resident #2 revealed no evidence that the wound care treatment, as prescribed by the the physician, was administered a total of twenty two (23) times to a wound on the sacral/coccygeal area. A total of twenty five (26) times to a wound of the groin/scrotal area and a total of twenty four (25) times to as wound to the right leg/thigh area. 3. Record review for Resident #3 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated the resident had one (1) Stage III pressure ulcer that was not present on admission to the facility. The CAA triggered pressure ulcers with the decision to be care planned. Revive of the Quarterly MDS assessment dated [DATE] indicated the resident had one (1) unstageable pressure ulcer. Review of the Care Plan initiated on 12/12/14 identified the resident is at risk for developing pressure ulcers and updated on 5/24/16 indicating a Stage II pressure ulcer to the the left medial ankle and on 6/24/16 indicating an unstageable pressure ulcer to the left foot. Review of the Physician order [REDACTED]. An order dated 3/15/16 for treatment to the left foot every Monday, Wednesday and Friday. Review of the TAR revealed no evidence or documentation that the treatment was administered on May 9 (W), 11 (W) and 18 (W). An order dated 5/23/16 revealed an order for [REDACTED]. Review of the TAR from May through July for Resident #3 revealed no evidence that the wound care treatment to the left medial ankle and foot, as prescribed by the physician, was administered for a total nineteen (19) times. Interview on 7/8/16 beginning at 10:40 a.m. with the Treatment Licensed Practical Nurse (LPN) FF revealed that a blank space with no signature on the TAR indicates, as far as she knows, that the treatment was not administered. The dressing changes have not been getting done consistently on the evening shift or weekends. She stated that she cannot handle everyone in the facility that requires wound care treatment and that there are thirty one (31) residents that require some form of wound care treatment. When she is off on the weekends, the nurses in care are responsible for the treatment but when she reviews the TAR on Monday, it has rarely been done. An interview on 7/8/16 at 1:11 p.m. with the DON revealed that she and the Assistant Director of Nursing (ADON) have helped with wound care treatments at times but not consistently. If the Treatment LPN is unable to administer treatment to a resident, it is the responsibility of the direct care nurse to provide the wound care. The DON confirmed that she did have a discussion with the nurses that if the Treatment Nurse could not complete any wound treatment that they are responsible for getting it done.

Based on observation, record review and interview, it was determined that the facility failed to ensure that one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin was free of a significant medication error from a sample of sixteen (16) residents. This failure resulted in harm for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer Insulin as ordered. review of the resident's medical record revealed [REDACTED]. [REDACTED]. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Continued review revealed that the resident received 1/2 amp of [MEDICATION NAME] (D) 50 and that her blood sugar level was currently 208. Further review revealed that her vital signs were stable and she was alert. Review of the hospital physician progress notes [REDACTED]. Continued review revealed that the resident's blood sugar levels stabilized and she was moved to the Medical/Surgical floor by 9/4/16. She was discharged back to the facility on [DATE]. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident's caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., twenty-four (24) hours after she had incorrectly administered 100 units of [MEDICATION NAME] to the resident and two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. Further interview revealed that she instructed the Certified Nursing Assistants (CNAs) to transfer the resident to the wheelchair, place her at EE's medication cart so that LPN EE could monitor her closely and LPN EE gave her Med Pass to drink. Continued interview revealed that the resident was alert and without symptoms of [DIAGNOSES REDACTED] when LPN EE left the facility at 11:00 p.m. Continued interview with LPN EE revealed that she notified the on-coming nurse LPN FF who worked 11:00 p.m. to 7:00 a.m. about the incident and instructed LPN FF to continue to monitor the resident. Interview on 9/22/16 at 1:55 p.m. with LPN GG via telephone revealed that she had observed LPN CC draw up the correct amount of [MEDICATION NAME] (12 units) and administer it to R#10 on 9/1/16 at 9:00 p.m. two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 4:00 p.m. with the Consultant Pharmacist via telephone revealed that he was unaware that nursing staff had administered 100 units of [MEDICATION NAME] instead of 12 units as ordered to R#10 on 8/31/16. Continued interview with the Consultant Pharmacist revealed that [MEDICATION NAME] was a long-acting Insulin and that the resident could possibly have abnormally low blood sugar levels up to twenty-six (26) hours after administration of such a high dose, especially if she was not eating well and nursing staff continued to administer Insulin. Further interview revealed that he expected nursing staff to hold the 6 units [MEDICATION NAME] R Insulin at 7:00 a.m. and the 12 units of [MEDICATION NAME] at 9:00 p.m. on 9/1/16. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/22/16 at 5:40 p.m. with the Nurse Practitioner (NP) via telephone revealed that she was in the facility on 9/1/16 but, that she was unaware that the resident had received the incorrect dose of [MEDICATION NAME] the night before on 8/31/16 at 9:00 p.m. until after the resident was hospitalized . Continued interview revealed that she had not been notified by staff of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. Further interview revealed that if nursing staff had notified her of the medication error from the previous night she would have notified the physician. Continued interview revealed that she would expect nursing staff to hold the 6 units of [MEDICATION NAME] R insulin at 7:00 a.m. Further interview revealed that the resident's blood sugar levels fluctuated but, she could not remember if the levels had ever been as low as 27 without reviewing the resident's medical record. Interview with LPN EE on 9/23/16 at 11:20 a.m. revealed that she and LPN CC, the new orientee, were the only nurses working on Unit II on 8/31/16 between 7:00 p.m. and 11:00 p.m. Continued interview revealed that she also needed to administer medications at that time and that CC told her she felt confident that she could administer the insulin. Continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven (7) rooms without problems; however, she did not observe LPN CC administer Insulin to those residents at that time. Further interview with LPN EE revealed that she had never observed LPN CC administer Insulin to any resident. LPN EE stated that LPN CC was a licensed nurse and should have been able to administer Insulin correctly. Continued interview with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Further interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interview on 9/23/16 at 1:23 p.m. with LPN FF, an agency nurse, via phone revealed that she worked 8/31/16 from 11:00 p.m. to 7:00 a.m. and took over the medication cart from LPN EE at 11:00 p.m. Continued interview revealed that she was not notified that LPN CC had administered an incorrect dose of insulin to R#10 at 9:00 p.m. and therefore, did not notify the physician of the error. Further interview revealed that she did not observe LPN CC administer any medications on her shift because she was an agency nurse and did not orient other nurses. Observation of R10 on 9/23/16 at 12:35 p.m. revealed that she was alert with confusion and without symptoms of [DIAGNOSES REDACTED]. She stated at that time that she was happy to be home. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. (100% as of 11/7/16) 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. (100% nurses were inserviced by 11/7/16) 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. (LPN no longer employeed at facility-she resigned) 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on record review and interview, it was determined that the facility failed to ensure that the clinical record for one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration was complete and accurately documented from a sample of sixteen (16)residents. The facility failed to ensure that a factual description of the medication error and the on-going monitoring of the condition for 24 to 72 hours was accurately and completely documented in the medical record as per facility policy for R10. The Administrator was informed on 10/31/2016, that a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R#10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident ' s caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., two hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked 7:00 p.m. to 11:00 p.m. on 8/31/16 when LPN CC administered 100 units of [MEDICATION NAME] to R10. Continued interview revealed that CC notified her of the medication error and that the resident was placed in a wheelchair by her medication cart, given Med Pass to drink and monitored closely. Further interview revealed that she notified the on-coming nurse FF at 11:00 p.m. to continue monitoring the resident. However, there was no indication that staff on subsequent shifts had been notified about the significant medication error. Interview with LPN EE again on 9/23/16 at 11:20 a.m. revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document any change in a resident's status or condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.

Based on observation, record review and staff interview the facility failed to assess and treat pain experienced during pressure sore treatments for two residents, #112 and #23 of thirty-three (33) sampled residents. This resulted in actual harm to residents #112 and #23. Findings include: 1. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed resident # 112 was assessed at risk for pressure sores and was assessed as having a Stage II pressure sore which was present on admission. Review of the current Comprehensive Care Plan revealed the resident had a current Stage II pressure sore on the left lateral foot. The Treatment Nurse and Certified Nursing Assistants (CNAs) "JJ" and "KK" were observed on 10/05/11 at 10:15 a.m. while doing a pressure sore treatment to the resident's left lateral foot. The resident called out in pain each time the wound was touched. The resident also verbally expressed pain when the old dressing was removed. The Treatment Nurse acknowledged the resident's expressions of pain and stated she would check with the Medication Nurse after the treatment to find out when he was last medicated. CNAs "JJ" and "KK" proceeded with the treatment. The resident asked the Treatment Nurse to check with the Medication Nurse. The Treatment Nurse left the room and returned stating he had his last pain medication at "2:o'clock". The treatment was completed. Review of the resident's current Physician order [REDACTED]. Review of the MAR for October 2011 revealed the resident received this medication for the first time in October 2011 on 10/05/2011 following completion of the pressure sore treatment. Review of the current Comprehensive Care Plan revealed the resident was care planned to receive support related to pain. Interventions included medicate for pain as needed and monitor effectiveness. 2. Review of the quarterly Minimum Data Set (MDS) Assessments dated 4/27/11 and 7/27/11 revealed resident # 23 had a healing Stage IV on the right heel. Review of the current Comprehensive Care Plan also revealed the resident had a Stage IV, now presenting as a Stage II on the right heel. Interventions included monitoring for pain and medicating as needed. The Treatment Nurse and Certified Nursing Assistants (CNAs), "JJ" and "KK" were observed doing the treatment to the pressure sore on 10/05/11 at 10:40 a.m. The resident winced when her foot was raised to begin the treatment. The resident winced and verbalized pain when the area was cleansed. CNA "JJ" asked her if it hurt and the resident said it hurt when touched. CNA "JJ" proceeded with the treatment. When the treatment was complete the Treatment Nurse asked the resident if she wanted a pain pill. The resident said it stopped hurting once the treatment was completed. Review of the current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the facility's policy on Pain Management revealed residents should be assessed and kept free of pain as much as possible. The facility's Pressure Sore Treatment Policy did not address pain The Treatment Nurse was interviewed on 10/06/11 at 11:20 a.m. and stated she did not feel resident #23 had pain during treatments, but acknowledged the resident did indicate pain when the area was touched. She further stated resident #112 did express pain during his treatment and that the treatment should have been stopped until the resident had pain medication with relief. During an interview on 10/06/11 at 12:25 p.m. the Director of Nursing (DON) stated she would have expected the nurse to stop the treatment, cover the wound with a dry sterile dressing (DSD), medicate the resident for the pain and wait an hour before resuming the treatment.