Every finding on record at Gateway Health and Rehab

Based on staff interviews, record review, and review of the facility's policy titled, Advance Directives, the facility failed to ensure that the electronic medical records, which included physician orders was consistent with the code status preference for one out of 25 sampled Residents (R) (R41). Findings include: Review of the facility's policy titled Advanced Directives dated November 2017 under the Policy Interpretation and Implementation section revealed, 10. The plan of care for each resident will be consistent with his or her documented treatments preferences and /or advance directive. Review of R41's Quarterly Minimum Data Sets (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 15 indicating that the resident's cognition was intact. Review of R41's Admission Packet revealed, an Advance Directives Checklist indicating a DNR (Do Not Resuscitate) order was selected, signed and dated on 6/11/2024 by the resident, the Resident's Representative, and the Facility's Representative. Further review revealed, the Do Not Resuscitate Order for Resident with Decision-Making Capacity form dated 6/11/2024 with a DNR order that was signed by the resident, a witness, and the attending physician. Review of R41's Admission Record revealed, an admitted [DATE] with an advanced directive code status documented as Full Code. Review of the Physician Orders dated 12/19/2024 revealed that R41 had a code status of Full Code. Review of the care plan revealed, R41 had an Advance Directive code status of DNR (date initiated 6/19/2024 with a revision date of 1/17/2025). Further review revealed, the care plan goal was that the resident's wishes will be followed, and comfort, care and safety needs will be met at the skilled nursing facility through next review date. Interview on 3/23/2025 at 11:00 am with Registered Nurse (RN) BB revealed that if the resident stopped breathing and a heart stopped beating that he would check in electronic medical records, so he could verify the resident's code status. He confirmed that the resident's code status in electronic medical records was a Full Code. He also confirmed that the check list titled Advanced Directives and DNR Order form revealed a code status of DNR. Interview on 3/23/2025 at 11:05 am with Licensed Practical Nurse (LPN) AA revealed that when residents go to the hospital all previous orders were discharged , and new orders were put in the system upon returning from hospital. She continued stating that Advanced Directive should be confirmed with the checklist on file. She also confirmed that the wrong status was entered in the electronic medical records. Interview on 3/23/2025 at 11:08 am with the Director of Nursing revealed her expectation for Advanced Directive code status that it should match both on paper and in the electronic medical records. She confirmed that the checklist titled Advanced Directive has a code status of DNR and the resident's Physician Order in electronic medical records has a code status of Full code.

Based on document observations, resident and staff interviews, record review, and a review of the facility's policy titled, Completion of Accident and Incident Form, the facility failed to identify accident hazards and implement interventions to address/reduce hazards for 1of 3 sampled residents (R) (#25). Specifically, R#25's arm became stuck in the grab bar beside the toilet. The facility failed to identify the grab bar as an accident hazard for R#25 and failed to implement interventions that addressed the grab bar. Findings included: Review of the facility's policy titled, Completion of Accident and Incident Form, dated 07/20/2021, specified, 1. A & I (Accident and Incident) data collection will be completed on: a. Bruises. The policy further indicated 7. The Director of Nursing or designee will investigate and complete the follow-up investigation. 8. The follow-up investigation must include appropriate interventions to reduce the risk of reoccurrence. 9. The incident will be reviewed in the Administrator's morning meeting by all disciplines. Weekend incidents will be investigated by the RN (Registered Nurse) Supervisor. He/She will notify the Care Plan Coordinator and therapy staff as is appropriate Review of the most recent quarterly Minimum Data Set (MDS) for R#25, dated 01/05/2023, revealed that R#25 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility, transfers, walking in room, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. The MDS revealed the resident had functional limitation in range of motion on one side in their lower extremity. Review of the care plan for R#25, initiated on 05/11/2022, revealed the resident had a self-care deficit related to activities of daily living (ADL). According to the care plan, the resident transferred independently, and staff could assist with transfers if needed. Further review revealed that the resident utilized the toilet and indicated that staff should check the resident for incontinent care and change the resident every two hours as needed. Review of Progress Notes for R#25, dated 01/31/2023 at 5:45 AM, revealed that the resident was in the restroom and turned on the emergency light. Upon entering the restroom, the resident was noted to have their left arm stuck in the grab bar beside the toilet. The resident stated they stood up to pull up their incontinent brief, and when the resident sat back down, somehow their arm got stuck. The note indicated that staff assisted the resident in removing their arm from the grab bar. The note indicated there was no apparent injury; however, the resident had burning to their upper arm. The note further revealed that the resident had good range of motion (ROM) and was assisted back to bed. Review of the Investigation Follow-up for R#25, dated 02/01/2023, revealed the date of the incident was 01/31/2023 at 5:45 a.m. The description of the incident indicated that R#25 was in the restroom and turned on the emergency light. The charge nurse entered the restroom, and the resident was noted to have their left arm stuck in the grab bar beside the toilet. The resident was assisted in removing their arm from the grab bar. According to the form, there was no apparent injury; however, the resident complained of 'burning' in the upper arm. The summary of the investigation did not show evidence that the facility identified the grab bar as a safety hazard for R#25 and implemented interventions to prevent further accidents. Review of the Progress Note for R#25, dated 02/02/2023 at 12:59 p.m., indicated the resident was reassessed after getting their arm stuck between the wall and grab bar on 01/31/2023 while toileting. The note indicated the resident had a hematoma on the left outer forearm, denied pain, and ROM was within normal limits. The note indicated that staff reiterated the importance of allowing staff to provide stand-by assistance while performing ADLs. The resident verbalized understanding and stated they would call for assistance. Interview and observation on 02/07/2023 at 8:23 a.m. with R#25 revealed that on the day of the incident, the resident was in the bathroom, and the resident's arm slipped between the grab bar and the wall. The resident was observed to have a brown bruise on the left arm just below the elbow. Observation on 02/07/2023 at 11:20 a.m. of R#25's bathroom revealed that the resident had changed rooms since the incident but continued to use the same bathroom. Observation revealed that the space between the grab bar and the wall measured four inches. Interview on 02/07/2023 at 9:00 a.m. with a Certified Nursing Assistant (CNA)1 identified the resident as being able to transfer themself to the toilet and would ask for assistance if needed. CNA 1 reported that a nurse told her about R25's 01/31/2023 incident. According to CNA 1, the nurse reported that the resident stood up, and the resident's left arm slipped behind the grab bar and got stuck. During a follow-up interview with CNA 1 on 02/07/2023 at 10:49 a.m., the CNA reported there was a risk of getting stuck in the rail for anyone. CNA 1 stated, maybe if the grab bar was closer to the wall, the resident might not have slipped and got their arm stuck in the rail. Interview on 02/07/2023 at 9:10 a.m. with a Licensed Practical Nurse (LPN) 2 revealed that R#25 transferred themselves to the bathroom and utilized the call light when the resident was finished using the bathroom. LPN 2 indicated she was not aware of any interventions to prevent recurrence but would review the incident report again. Interview on 02/27/2023 at 9:23 a.m. with the Director of Nursing (DON), she stated that staff reported R#25 was in the bathroom, the resident stood up, and when the resident held onto the grab bar to sit down, the resident's arm got caught. The DON reported that an incident report was completed, and the resident had a bruise the next day that was monitored. According to the DON, the CNA had left the bathroom to give the resident privacy. During a follow up interview with the DON on 02/07/2023 at 11:06 a.m., she indicated the root cause of R#25's injury was the older, larger grab bar. The DON reported that the grab bar had been discussed with the maintenance staff a while back. The DON stated that maintenance replaced the grab bar with a new type, and the CNA placed a walker in front of the resident to assist with standing and sitting while on the toilet. However, a review of R#25's care plan revealed no interventions to prevent reoccurrence. Interview on 02/07/2023 at 11:22 a.m. with the maintenance staff revealed he was not aware of R#25's grab bar incident until the morning meeting on Friday, 02/03/2023. The maintenance staff stated the problem was that there was a four to six inch gap between the wall and R#25's grab bar. He stated that the new grab bars were two inches off the wall. Interview on 02/08/2023 at 8:53 a.m. with the DON, indicating LPN 3 completed the incident report investigation for R#25. She stated that LPN 3 felt the root cause was the resident getting up unassisted, and the resident had been educated not to get up unassisted. Interview on 02/08/2023 at 9:32 a.m. with LPN 3 revealed she interviewed R#25, and the resident stated their hand slipped down into the grab bar, which caused a hematoma to the left forearm. According to LPN 3, the resident was encouraged to call for assistance. LPN 3 stated she guessed the resident's arm got caught in the grab bar because the bar was too far away from the wall. Interview on 02/08/2023 at 10:14 a.m., the Administrator stated that R#25's arm got stuck in the grab bar, and the charge nurse was able to pull it out, which resulted in a bruise. The Administrator reported that LPN 3 was currently responsible for the investigation, and the interdisciplinary team would determine the root cause. The Administrator reported that the grab bar in R#25's bathroom was not changed until yesterday (02/07/2023), and maybe it would be safer.

Based on observation, interview and review of facility policy, the facility failed to implement infection control practices by not following proper glove use procedures and not utilizing a gown or other barrier to prevent cross-contamination when sorting laundry. These practices occurred during a COVID-19 outbreak at the facility. Findings include: The facility's policy Departmental (Environmental Services) - Laundry and Linen Version 2.2 revised 01/14 revealed that Standard Precautions 3. Consider all soiled linen to be potentially infectious and handle with standard precautions. Sorting Soiled Linen 1. Employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected. 2. Use heavy-duty rubber gloves for sorting laundry. Always wash hands after the task and removing gloves. Observation on 8/19/21 at 10:00 a.m. revealed Laundry Aide (LA) CC in hallway of 200 unit placing soiled linen in a collection barrel while wearing blue examination gloves. LA CC rolled the collection barrel to the soiled laundry area, removed the key holder from its hook, opened the laundry room and put the key back on its hook. LA CC then sorted the linen by color into two containers, placed the linen into two separate washing machines, closed the doors, and started the machines prior to removing the soiled gloves and washing her hands. Disposable gowns were observed on top of the washing machine but were not used by LA CC. Interview on 8/19/21 at 10:10 a.m. LA CC confirmed using soiled gloves to handle the key holder which is shared by other staff. She also stated that she only uses the gowns when handling laundry from the COVID unit. Interview on 8/19/21 at 10:25 a.m. the Housekeeping/Laundry Manager (HLM) reported that LA CC would have been expected to change her gloves after gathering the soiled linen. After reviewing the facility laundry policy, the HLM confirmed that LA CC should have used long rubber gloves for sorting the laundry as per company policy, but they did not have them available. She also confirmed that a gown should be used as a barrier to prevent cross-contamination when sorting laundry. Interview on 8/19/21 at 2:08 p.m. with the Director of Nursing revealed that LA CC did not follow protocol for glove use.

Based on observation, record reviews, interviews, and review of facility policy, it was determined for one of 13 sampled residents (Resident (R) #1) the facility failed to ensure that the resident's environment remained free of accident hazards as possible, and that the resident received adequate supervision as well as assistance to prevent accidents. Findings Include: Review of the policy entitled. Accidents and incidents investigating and Reporting, dated May 2009 revealed: SCOPE: This policy applies to the staff at the healthcare center. 1. Reporting of Accidents/Incidents: c. An employee witnessing an accident or incident should report the occurrence to his/her immediate supervisor as soon as practical and write a witness statement describing the accident/incident. Do not leave an accident victim unattended unless it's absolutely necessary to summon assistance. d. The nurse supervisor/charge nurse should be immediately informed of accidents/incidents so that medical attention can be provided. 2. Assisting Accident/Incident Victims: a. Should you witness an accident, or find it necessary to aid an accident victim, you should render immediate assistance. Do not move the victim until he/she has been examined for possible injuries. b. If possible, move the injured to the treatment room, or if it is a resident in his/her room move the resident to his or her bed. c. If assistance is needed, summon help. If you cannot leave the victim, ask someone to report to the nursing station that help is needed, or if possible, use the call system located in the resident's room to summon help. 3. Medical attention: The nurse supervisor and/or charge nurse will: a. Examine all resident (s) involved in the accident or incident. b. Notify the residents personal or attending physician and inform the physician of the accident or incident. Document clearly on the Accident/Incident Report form and in the nurses note form of notification that was used, for example if you faxed the report then document faxed report to MD, if placed in MD communication book then document in MD's communication book, if per phone then write MD notified per phone. c. If necessary, obtain a physician order to transfer the injured resident to the emergency room . d. If necessary, designate an employee to accompany the resident to the emergency room , medical treatment center or hospital. (This will be determined by a member of Nursing Management or Administrator.) e. A Neurological Assessment to include vital signs will be initiated on all residents with an un-witnessed fall, any unwitnessed fall or other incident with a blow to the head) with or without apparent injury), and/or suspected head injury. The [NAME] Neurological Assessment Flow Sheet CFS6-19.1 will be used to document this. Neurological Assessments will be performed by the licensed nurse every Fifteen (15) minutes times four, every one-hour times four, every two hours times four, then every four hours times four, then every eight hours times four -this frequency may not be reduced; however, the physician may order the neurological checks at more frequent intervals. Vital signs will be obtained hourly for the first five hours, then with each Neurological Assessment, and documented on the [NAME] Neurological Assessment flow sheet. Upon completion of the assessment period and if there are no issues identified the neurological assessments may be discontinued at this time unless otherwise ordered by the MD. 4. Investigative Action: a. The Nurse Supervisor/Charge Nurse and/or the department manager or supervisor must conduct an immediate investigation of the accident or incident. b. A completed Accident/Incident Report Form must be submitted to the Director or Nursing when completed. 5. Accident/Incident Report: a. The Nurse Supervisor/Charge Nurse and/or the department manager or supervisor will: 1. Complete an Accident/Incident Report form and submit it to the Director of Nursing. 2. The person completing a resident Accident/Incident report form will complete the A&I Review form and submit it with the Accident/Incident Report Form to the Director of Nursing. (A & I review form included in the Accident/Incident forms completion of policy.) 3. If method of MD notification is by fax please attach a copy of the fax confirmation sheet to the Accident/Incident Report form. 4. The Director of Nursing or designee will complete the follow up investigation. 5. Accidents and Incident Report forms, Investigate/Follow up forms, A&I review forms, and Neurological forms will be maintained at each nursing station. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 4/5/2021, to have diagnoses of repeated falls, age related physical debility, abnormal gait of mobility, essential (primary) hypertension, muscle weakness, difficulty walking, unspecified [CONDITION(S)], chronic pain, generalized [CONDITION(S)], other symbolic dysfunctions, gastro reflux disease without esophagitis, conjunctival [CONDITION(S)] unspecified eye, polymyalgia rheumatica, non-surgical orthopedic/musculoskeletal, allergic rhinitis, constipation, cough, vitamin D deficiency. R#1 had a Brief Interview for Mental Status (BIMS) score of 7 indicating impaired cognition. The MDS revealed Resident #1 did not participate in skilled therapies but received restorative nursing programs during the assessment review period. Under Section G functional status, the resident was coded as requiring two-person assist from staff for activities of daily living including bed mobility, transfers, toileting, and the use of mobility devices such as wheelchair (manual or electric) Review of the Care Plan dated, 4/8/21, revealed R#1 has potential for injury and is at risk for fall, her most recent fall risk assessment score 55. Under the goals section, the resident will have no falls with injury requiring hospitalization from falls though next review. Under the approaches section, staff to apply non-skid socks, be sure the residents call light is within reach and encourage the resident to use it for assistance as needed, ensure bed is kept in lowest position, ensure bed/wheelchair is locked during transfer, ensure that the resident is wearing not skid shoes or socks when ambulating or mobilizing in wheelchair. Fall risk assessment upon admission, readmission and quarterly. Keep room and common areas free from clutter. Keep personal care items within easy reach. Place a star by the resident's name on the door to their room. Therapy to screen quarterly and prn. Watch for dizziness when changing position to sitting or standing and encourage resident to pause for a few. Review of the facility's Observation fall risk quarterly assessment score, dated 4/5/2021, revealed that R#1 had a total fall risk score of 55, indicating the resident was at high risk of falls. Review of the facility's Accident or Incident Investigation follow up Report dated 3/15/21, revealed R#1 had an un-witness fall and was observed in her wheelchair and had tipped her wheelchair backwards and hit her head on the ground. R#1 is alert with confusion and was in her wheelchair in her room, roommate is ambulatory and has dementia frequently tries to assist/take care of resident. It appears that resident may have attempted to stand up but fell back into wheelchair causing it to tip backward and falling and was found to have a hematoma to back of head. The resident was sent to emergency room (ER) for evaluation. Neuro-checks were instituted per protocol. Review of the facility's Accident or Incident Investigation follow up Report, dated 5/20/2021, revealed Certified Nursing Assistant (CNA) had assisted R#1 up to her wheelchair and was attempting to prop the resident's legs on her bed to help with swelling. CNA reported that wheelchair started tipping over and she could not catch the wheelchair before it fell . Upon arrival of nurse the resident was noted to be laying on her back while still in the wheelchair. On 5/21/21 R #1 sent to emergency room (ER). The facility could not provide'' the ER reports for the 5/21/21 ER visit for R#1. The facility could not provide any in-services related to ensuring staff were educated on safe transfers or interventions to prevent falls. Observation of R#1 on 7/21/21 at 9:40 a.m. revealed the resident was dressed, well-groomed, and sitting up in her room in the Broda chair with white socks on. Observation of R# 1 on 7/21/21 at 11:30 a.m. dressed, well- groomed and sitting up in her Broda chair in activities playing ball, with white socks on. Observation of R#1 on 7/22/21 at 11:30 a.m. resident sitting in her Broda chair in activities listening to music has on yellow non-skid socks. An interview was conducted on 7/21/21 at 7:13 p.m. with family of R#1 revealed that she was notified right away of the fall, we spent time in the ER, they ran tests, and everything was fine. It is hard with Covid-19 to know what's going on. We loved to come visit her during activities, eating and physical therapy, after the fall she complained of back pain for several weeks. An interview on 7/22/21 at 7:51 a.m. with License Practical Nurse (LPN) DD, revealed, R#1 is two- person assist with sit to stand and after transferring the resident to the wheelchair, Certified Nursing Assistant (CNA) AA was attempting to place the resident legs on the bed to help with leg swelling. The resident's wheelchair was not locked, and she fell backwards onto the floor hitting her head. LPN AA revealed that she had been off for several days after R#1 fell and was not working when the resident was sent to the hospital. An interview on 7/22/21 at 9:32 a.m. with CNA AA revealed, that she went to prop R#1's legs up on the bed due to her feet swelling and the resident pushed back. The resident's bed was low but she fell back in the wheelchair hitting her head. CNA AA revealed that she was not certain if the wheelchair was locked. The CAN revealed that no one was in the room with me when the resident fell . CNA AA stated, I am not sure if there was an order for propping the resident's feet up, but I was informed by the nurses to do that, we've always done it. An interview with the DON on 7/22/21 at 12:29 p.m. revealed that CNA AA had come in early to help get residents up for the day and was putting R#1 in her wheelchair. The resident requires a two person assist for transfers. She revealed that CNA AA was trying to elevate the resident's legs onto the bed which caused the wheelchair to tip backwards, and the resident hit her head on the floor. The only injury, at the time, was redness to the back of the head there was no indication that she was injured. The following day the resident threw up and complained of back pain and the Physician gave the order to send her to the ER. The DON revealed the wheelchair was not locked at the time of the incident which was a missed judgement by CNA AA. My expectation is that CNA AA should have kept the wheelchair locked or put the resident in the Broda Chair.

Based on observations, record review, interviews, and facility policy, the facility failed to inform the resident's representative of a significant weight loss for one Resident (R) #41 in accordance with the right to be informed. The sample size was 14. Findings include: Review of facility's policy entitled Residents Rights effective date 10/2017, noted the following Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: K. Appoint a legal representative of his or her choice, in accordance with state law. O. Be informed of his or her medical condition and of any changes in his or her condition. P. Be informed of and participate in his or her care planning and treatment. Policy Interpretation and Implementation: The Nurse will notify the resident's Representative of Any significant change of condition or major decline in the resident's status that will not normally resolve itself without interventions by staff or by implementing standard related clinical interventions (is not self-limiting). A review of the Resident's Face Sheet revealed, Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did have a Responsible Party (RP) listed on the Admission Face Sheet. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment of 11, indicating cognitively intact. Review of Nurse's Note dated 6/16/21 revealed, monthly weight triggered a significant weight loss for June 2021 for 90 and 180 days with the resident's weight checked twice. Resident was added to weekly weights and Patients at Risk (PAR), the Physician was notified and new order for Ready Care (RC) 2.0, 90 milliliters (ml) three times daily (tid) as a supplement. Further review of meal intakes revealed a poor appetite overall mostly 0-25% but some 26-50% documented as well, which was normal for R#41. Average meal intakes for past 7 days 11-36%. The resident had an admission weight of 110 pounds on 5/6/2020. Resident steadily gained through October 2020 which resulted in triggering a significant weight gain. The resident's weight then stabilized around 119 pounds but has slowly decreased each month since March 2021. Resident eats in her room and is on a high Protein diet with large protein portions but resident does not eat the large portions. The resident has a history of anxiety and will often get focused on random things like wanting her blood pressure checked repeatedly or walking to the nurse requesting an aspirin for a headache or complaining of (c/o) of nausea at mealtimes. Will monitor weights weekly and meal intakes and discuss during PAR. Review of the Registered Dietitian notes dated 6/16/21 revealed, recommendation to decrease RC 2.0 to twice (bid) daily and add ice cream with lunch and dinner meals. The doctor is in agreement with the dietary communication note completed to add ice cream with lunch and dinner trays. The resident and RP were notified. An interview on 7/21/21 at 6:04 p.m. with the family of R #41, revealed, I have never been contacted or informed of her significant weight loss, she would not drink Ensure at home or supplements. I have not heard a word about the weight loss and every time we call, they tell me that she is fine. The family further revealed that they have not seen her in two weeks and the facility calls when the resident is aggressive or problems, this is the first I've heard about her weight loss, I've even talked to the Physician, and he has never mention anything about weight loss or talked to us about an appetite stimulant to help. The family confirms that no one from the facility has contacted her with weight loss concerns. An interview with the Director of Nursing (DON) on 7/22/21 at 12:21 p.m. revealed that she is responsible for notifying the family of R#41 of weight loss. The DON revealed that she had spoken to the RP for the resident this morning about a new order and the RP stated that she was not aware of the resident's weight loss. The DON could not explain why she had not notified the family, as this is her responsiblity.

Based on interview and record review the facility failed to ensure a Certified Dietary Manager with appropriate credentials was employed. This deficient practice had the potential to effect 45 of 45 residents who received meals in the facility. Findings include: During the initial tour of the kitchen on 7/20/21 at 1:23 p.m. the Dietary Manager (DM) was asked to provide her credentials for serving as the DM. She stated that she did not have the credentials yet but was enrolled in the course. She stated she had been employed in her position since December 2020, but had worked as a CNA at the facility since January 2020. She stated that the Registered Dietitian was not full-time and came to the facility on ce a month. In an interview with the Administrator on 7/22/21 at 3:36 p.m. she stated that she was aware the DM was not certified. She stated that she knew the DM needed to be certified but thought she had a year from hire to obtain her certification. She stated that she had been told by their regional office they had one year to obtain the certification. The Administrator was referred to the Association of Nutrition and Foodservice Professionals (ANFP) website. The following information on the website was documented; As of November 28, 2017, newly-hired Food Service Directors must meet the qualifications specified in the regulations and are no longer within the one-year window for obtaining certification. The Certified Dietary Manager, Certified Food Protection Professional (CDM, CFPP) credential is now listed as the primary qualification for the Director of Food and Nutrition Services in the absence of a full-time dietitian.

Based on observation, review of the facility policy titled Storage of Medications and staff interviews, the facility failed to ensure that one of two medication carts was locked and medications secured when not in use. The facility census was 57 residents. Findings include: Review of the facility policy titled Storage of Medications revised (MONTH) 2007 revealed: the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biological shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 10. Only persons authorized to prepare and administer medications shall have access to medication room, including any keys. Observation during a fasting blood sugar check for R#26 revealed Licensed Practical Nurse (LPN) CC entered the resident's room on 9/22/18 at 3:50 p.m. and left the medication cart unlocked with cart keys laying on top of the cart. LPN CC exited the resident's room and prepared insulin as ordered. At 3:56 p.m., she entered the resident's room again leaving the medication cart unlocked with insulin bottle and cart keys on top of the cart. Interview with LPN CC on 9/22/18 at 4:00 p.m. revealed that those were her keys and she usually doesn't leave the cart unlocked, keys on top or insulin on top of cart. She stated that she doesn't usually bring the cart with her to do a blood sugar check. Interview with the Director of Nursing (DON) on 9/23/18 at 9:00 a.m. revealed that she expects staff to lock the cart and all medications should be locked in the cart when unattended. She expects the nurse to keep cart keys in her pocket at all times.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to the Preadmission Screening and Resident Review (PASRR) for four residents (#32, #50, #58, and #65). The sample size was 28. Findings include: 1.) Review of the clinical records reveal Resident (R) #50 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the Level II PASRR Outcome Notification for the resident dated 1/5/15 revealed a PASRR level II review was completed for the resident to determine whether nursing facility placement was appropriate and to determine what mental illness/intellectual disability services the resident would need, including what services could be provide by the facility, and what specialized services should be arranged for through another entity. Review of the Annual Minimum Data Set (MDS) for the resident with reference date of 7/7/17 documented in Section A1500 - Preadmission Screening and Resident Review (PASRR) that the resident had not been evaluated by Level II PASRR and found to have a serious mental illness. 2.) Review of the clinical records reveal R#58 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the Level II PASRR Outcome Notification for the resident dated 8/20/15 revealed a PASRR level II review/assessment was completed for the resident and this review determined that the resident had a serious mental illness and met nursing facility level-of-care requirements. Review of a Significant Change Minimum Data Set (MDS) for the resident with reference date of 11/2/16 documented in Section A1500 - Preadmission Screening and Resident Review (PASRR) - that the resident had not been evaluated by Level II PASRR. 3.) Review of the clinical records reveal R#32 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the Level II PASRR Outcome Notification for the resident dated 8/28/17 revealed a PASRR level II review/assessment was completed for the resident and this review determined that the resident had a serious mental illness and met nursing facility level-of-care requirements. Review of an Admission MDS assessment of 8/11/17 documented in Section A1500 - Preadmission Screening and Resident Review (PASRR) - that the resident had not been evaluated by Level II PASRR and found to have a serious mental illness and met nursing facility level-of-care requirements. 4.) Review of the clinical records reveal R#65 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Level II PASRR Outcome Notification for the resident dated 11/4/16 revealed a PASRR level II review/assessment was completed for the resident and this review determined that the resident had a serious mental illness and met nursing facility level-of-care requirements. Review of an Admission MDS assessment of 11/24/16 documented in Section A1500 - Preadmission Screening and Resident Review (PASRR) - that the resident had not been evaluated by Level II PASRR and found to have a serious mental illness and met nursing facility level-of-care requirements. Interview on 9/17/17 at 11:37 a.m. with the MDS Coordinator revealed that R#32, R#50, R#58, and R#65 had been coded incorrectly on the MDS assessments because she was not aware that these residents had been assessed by Level II PASRR. To her knowledge, there were no residents currently residing in the facility for whom Level II PASRR assessments had been completed. Interview on 9/17/17 at 2:25 p.m. with the business office manager revealed she is responsible for receiving and filing the Level II PASRR assessment documents for all residents arriving at the facility with such an assessment. If a resident requires a Level II assessment/screening after arriving at the facility, the business office manager is also responsible for requesting this assessment and filing any associated findings/records in the residents' records. The Level II documentation is kept in the resident's records in the business office and the business office notifies the MDS coordinator. The business manager confirmed that Residents #32, #50, #58, and #65 each had a Level II PASRR assessment and findings filed in their records and this should have been communicated to the MDS coordinator.

Based on record review and staff interviews, the facility failed to develop an individualized, comprehensive Care Plan related to nutritional status for one (1) resident (R65) from a sample of twenty nine (29) residents. Findings include: Record review for R65 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] that indicated admission to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Section C- Cognitive patterns, documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of five (5), indicating severe cognitive impairment. Section G- Functional Status documented the resident required limited assistance with one (1) person physical assist with eating. Section M- Skin Conditions documented the resident did not have unhealed pressure ulcers but was at risk for pressure ulcers. Section K- Swallowing/Nutritional Status documented no weight loss or weight gain of 5% in one (1) month or 10% in six (6) months. Section V- Care Area Assessment (CAA) triggered Activities of Daily Living (ADL) Function, Pressure Ulcers and Nutritional Status with the decision to be care planned. Review of the Care Plan for R65, which was updated on 10/16/15, revealed no evidence of a care plan in place with measurable goals and interventions related to nutritional status. Interview on 01/07/2016 at 4:03 p.m. with the Director of Nursing (DON) confirmed a Care Plan related to Nutritional Status and/or Weight Loss for R65 had not been developed. The DON stated the resident was seen by the Registered Dietician (RD) and that the Certified Nursing Assistant (CNA) Flowsheet addressed provision of water and meal assistance for R65. An interview on 01/07/16 at 4:40 p.m. with the MDS Registered Nurse (RN)/Care Plan Coordinator revealed once a MDS assessment is complete, Care Plans are developed based on the triggers identified in the CAA summary. The MDS RN confirmed that an intervention of nutritional supplement was added later to the Care Plan related to skin breakdown and that nutrition and/or weight loss was not specifically addressed for R65.

Based on observation, record review and staff interview, the facility failed to follow a Care Plan intervention related to the use of an apron while smoking for one (1) Resident (R10) out of five (5) residents identified as smokers. The sample size was twenty-nine (29) residents. Cross refer F323 Findings include: An observation on 01/04/16 at 2:45 p.m. of the resident smoking area revealed R10 outside smoking without a smoke apron. There was no observed smoking apron in the smoking area. No staff members were present, however, the resident was accompanied by his daughter. There were no other residents smoking at this time. Review of the Care-plan for R10, which was updated on 12/3/15, revealed Resident has potential for personal injury related to smoking and the handling of smoking materials. Interventions included, but not limited to: Resident's room will be searched weekly for smoking materials. Resident will agree to comply with facility policy, including smoking only at designated times in designated areas and with the use of a smoking apron. Resident will allow smoking materials to be kept in a secure location at the Nurse ' s Station, Staff to accompany resident to smoking areas for supervised smoking. Review of the Smoking Policy and Procedure documented the facility will ensure the safety of residents is protected by close supervision of residents who smoke. Residents will use smoking aprons provided by the facility for all smoking residents. Families/visitors may take a resident to smoke during their visit following instruction from the Charge Nurse regarding the facility policy. There was no evidence available to confirm the daughter of R10 was instructed on the facility policy for smoking. An interview with the certified nursing assistant (CNA) CC supervising the smoke break on 01/06/2016 at 2:31 p.m. revealed the residents are assisted to the smoking area by staff or a family member and are allowed ten minutes to smoke. CC confirmed that she keeps all supplies and hands out the cigarettes, then lights the cigarettes. CC further stated the aprons are placed on the resident's and should be worn every time a resident smokes during a smoke break. An interview with the Licensed Practical Nurse (LPN) BB on 01/07/2016 at 2:11 p.m. revealed that she hands the family member the smoking material and apron and the family member escorts the resident out to the designated smoking area. BB confirmed that the staff do not supervise the resident when the resident's family member is present. An interview with LPN AA on 01/07/2016 at 2:25 p.m. revealed that a family member is allowed to take the resident out to smoke any time. The family member is given the smoking supplies and smoking apron to assist the resident once outside. AA further stated that family members are not provided with instructions regarding the smoking supplies.

Based on observation, record review, Smoking Policy and Procedure review, and staff interviews, the facility failed to supervise smoking and provide a smoking apron for one (1) resident (R10) out of five (5) residents identified as smokers. The sample size was twenty-nine (29) residents. Findings include: An observation on 01/04/16 at 2:45 p.m. of the resident smoking area revealed R10 outside smoking without a smoke apron. There was no observed smoking apron in the smoking area. No staff members were present, however, the resident was accompanied by his daughter. There were no other residents smoking at this time. Record Review for R10 revealed and Annual Minimum Data Set (MDS) assessment dated [DATE] documented in Section C- Cognitive Patterns, that the resident had a Brief Interview for Mental Status (BIMS) summary score of fourteen (14) indicating cognitively intact. Section G- Functional Status documented the resident with limitations in range of motion due to impairment on one side for upper and lower extremities. Section J- Health Conditions documented the resident as a current tobacco user. Review of the Care-plan for R10, which was updated on 12/3/15, revealed Resident has potential for personal injury related to smoking and the handling of smoking materials. Interventions included, but not limited to: Resident's room will be searched weekly for smoking materials. Resident will agree to comply with facility policy, including smoking only at designated times in designated areas and with the use of a smoking apron. Resident will allow smoking materials to be kept in a secure location at the Nurse's Station, Staff to accompany resident to smoking areas for supervised smoking. Review of the Smoking Assessment for R10 dated 11/18/15 indicated resident is able to physically hold the cigarette and remains alert during the course of smoking. Review of the Smoking Policy and Procedure documented the facility will ensure the safety of residents is protected by close supervision of residents who smoke. Residents will use smoking aprons provided by the facility for all smoking residents. Families/visitors may take a resident to smoke during their visit following instruction from the Charge Nurse regarding the facility policy. There was no evidence available to confirm the daughter of R10 was instructed on the facility policy for smoking. An interview with the Certified Nursing Assistant (CNA) CC supervising the smoke break on 01/06/2016 at 2:31 p.m. revealed that the residents are assisted to the smoking area by staff or a family member and are allowed ten minutes. CC confirmed that she keeps all supplies and hands out the cigarettes, then lights the cigarettes. CC informed that aprons are placed on the resident's and should be worn every time during the smoke breaks. CC stated that the R10 smokes her cigarettes all the way down to the end. An interview with the Licensed Practical Nurse (LPN) BB on 01/07/2016 at 2:11 p.m. revealed that she hands the family member the smoking material and apron and the family member escorts the resident out to the designated smoking area. BB confirmed that the staff do not supervise the resident when the resident's family member is present. An interview with LPN AA on 01/07/2016 at 2:25 p.m. revealed that a family member is allowed to take the resident out to smoke any time. The family member is given the smoking supplies and smoking apron to assist the resident once outside. AA further stated that family members are not provided with instructions regarding the smoking supplies.

Based on review of resident trust fund accounts and staff interviews the facility failed to ensure that acceptable accounting principles were maintained for four (4) residents (#13, #35, #9, #51) from forty-two (42) residents trust fund accounts reviewed. Findings Include: Interview on 2/5/2015 at 10:47 AM with Financial Services Coordinator, "AA" revealed she was made aware there were discrepancies with the facilities accounting in November 2014 when she was brought in to audit. She further indicated that the resident trust fund accounts had not been reconciled since December 2013. She has reconciled accounts from September 2014 and built the resident trust fund accounts from October 2014 thru December 2014. All resident accounts managed by the facility were reviewed with " AA " , Business Office Manager, Accounts Payable and Social Services. Receipts for withdrawals and Liabilities on each account were reviewed. Concerns with Resident Accounts were as followed: 1. On 11/7/14 Resident #13 had $74.47 withdrawn in error, check # 3893. These monies were supposed to be withdrawn from resident #20. Further review revealed that on 11/7/14 another withdrawal for $28.35 was made, which left a negative balance of $17.97. On 11/26/14 $16.86 was withdrawn, with a negative balance of $34.83. 2. Resident #35 had a withdrawal on 12/9/14, Check #3913, and on 12/23/14, Check #3919, each for $50.00 were withdrawn without a receipt. "AA" indicated that she believed these were input errors. On 12/10/14 the resident responsible party withdrew $50.00 , without how it was used for the resident. Check # 3913 left the resident with a negative balance of $38.20 which increase to a negative balance of $88.20 with Check #3919. The ledger indicated that check #3919 was to petty cash. Review of check copy revealed the amount was for Cash for $160.80 to replish cash. 3. Review of the resident's ledger record revealed Resident #9 had a negative balance for 10/6/14 until 12/31/14. 4. On 10/1/14 Check# 3869 was written to a family member of resident # 51 for $41.42, this person was not the residents' responsible party. "AA" is not sure if this withdrawal is from correct resident. Review of facility policy on resident trust funds indicates the facility must maintain a separate, accurate and complete accounting of the Resident Trust Fund. All disbursement slips, receipts or other documentation bearing the signature of the resident or responsible party must be kept in the resident ' s financial folder. The Resident trust will be reconciled monthly. Interview with Administrator on 2/5/2014 at 11:47 AM revealed she was made aware of discrepancies with the resident trust fund in November of 2014 when the Business office Manager at that time resigned.

Based on review of resident trust accounts and staff interviews, the facility failed to ensure that resident personal funds were disbursed within thirty (30) days of death for nine (9)("A", "B", "D", # 7, #15, #26, #32, #33 and #53) of fifteen (15) accounts reviewed. Findings include: Interview with Financial Services Coordinator "AA" on [DATE] at 10:47 AM revealed the previous Business Manager resigned in [DATE] and she was made aware that there were several resident trust accounts that were not disbursed within thirty (30) days of death. Review of facility policy revealed Patient Trust Fund accounts must be closed within thirty (30) days after the resident expires, the check should be made payable to the Estate of the resident. Review of resident trust accounts on [DATE] at 10:45 AM revealed the following: 1. Resident #32 expired on [DATE] and $1339.95 was dispersed on [DATE]. 2. Resident #15 expired on [DATE] and $275.87 was dispersed on [DATE]. 3. Resident #7 expired on [DATE] and $9.17 was dispersed on [DATE]. 4. Resident #26 expired [DATE] and Check 3927 for $71.20 was written on [DATE]. 5. Resident #53 expired on [DATE] and $296.57 was dispersed on [DATE]. 6. Resident #33 expired on [DATE] and Check 3917 for $1050.75 was written [DATE]. 7. Resident "A" expired [DATE] and Check 3705 for $116.01 was written on [DATE]. 8. Resident "B" expired [DATE] and Check 3777 for $40.52 was written on [DATE]. 9. Resident "D" expired [DATE] and account has not been closed as of [DATE]. There is a balance of $114.27 in the account. Interview with Administrator on [DATE] at 11:47 AM revealed she was made aware in [DATE] that several funds had not been closed out on expired residents.

Based on clinical record review, staff interview, and hospital document review, the facility administration failed to ensure that resident drug therapy was provided in accordance with physician's orders [REDACTED].#1), who was administration the narcotic [MEDICATION NAME] in the absence of a physician's orders [REDACTED]. Resident #1, who did not have a physician's orders [REDACTED]. Resident #1 was later observed to be unresponsive to verbal or painful stimuli, was transported to the hospital and was noted to be somnolent and to have pinpoint pupils. An emergency room toxicology screen revealed a toxic [MEDICATION NAME] level. Resident #1 was then admitted to the Intensive Care Unit and received a [MEDICATION NAME] drip and intravenous fluids for [DIAGNOSES REDACTED]. The failure of the facility's administration to ensure the accurate administration of medication to Resident #1 resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on January 15, 2014 at 2:55 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 25, 2013 (the date the facility concluded that Resident #1 received [MEDICATION NAME] in error), continued through January 16, 2014, and was removed on January 17, 2014. During the January 15, 2014, 2:55 p.m. interview referenced above, the Administrator acknowledged the medication error involving Resident #1 having received [MEDICATION NAME]. During a January 16, 2014, 12:30 p.m. interview, the Administrator also acknowledged being aware of the facility having been cited for a medication error rate in excess of five (5) percent during the standard survey of August 16, 2013. An allegation of jeopardy removal was received on January 16, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 17, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating nursing staffs' compliance with physicians' orders during medication administration, to ensure accurate medication administration, continued. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Observations were made of medication administration to residents to assess staffs' conformance with physicians' medication orders. Findings include: Cross refer to F333. Based on clinical record review, hospital record review, and staff interview, the facility failed to ensure that Resident #1 was free of a significant medication error involving the narcotic [MEDICATION NAME]. Resident #1, who had [DIAGNOSES REDACTED]. During an interview with the Administrator conducted on 01/16/2014 at 12:30 p.m., the Administrator was questioned regarding the facility's medication administration process, and also about the incident involving the significant medication error during which Resident #1 received [MEDICATION NAME] without a physician's orders [REDACTED].#1 becoming toxic with [MEDICATION NAME]. The Administrator stated that when the facility became aware of the medication error involving Resident #1, interventions had been developed to address the error, including immediate staff in-service training on the facility's medication administration policies and procedures, a complete chart audit for all residents, and a medication cart audit to ensure such things as correct medication labeling and accurate instructions for medication administration. During a 01/20/2014, 10:53 a.m. post-survey Quality Assurance telephone interview with the facility's Administrator, in reference to the facility's process of conducting drug cart audits, the Administrator stated that the process of weekly drug cart audits by the Patient Care Coordinator being utilized as part of the corrective plan to address the medication error involving Resident #1 had been in place for quite some time, even prior to the medication incident involving Resident #1. This weekly drug cart audit had continued by the Patient Care Coordinator after Resident #1's medication error as well. The Administrator acknowledged that it was only on 01/16/2014 (approximately three (3) weeks after the significant medication error involving Resident #1) that the facility had made the decision to include a second supervisory staff, that person being the ADON, in the weekly drug cart audits to ensure an accurate audit. In addition, the Administrator also acknowledged that the tool (the Med Care Audit Form) to be utilized to conduct and document this drug cart audit, and to allow for the ongoing analysis of the drug cart audit process by facility supervisory staff and the QA Committee, had not been developed and implemented until 01/16/104. Additionally, during the 01/16/2014, 12:30 p.m. interview referenced above, the Administrator acknowledged being aware of the facility having been cited for a medication error rate in excess of five (5) percent during the standard survey of August 16, 2013, approximately four months prior to the medication error involving [MEDICATION NAME] administration to Resident #1. The Administrator stated that as a result of the August 2013 standard survey citation involving medication errors, periodic medication pass observations had been conducted by supervisory staff to audit medication administration. During this interview, the Administrator acknowledged the need for more supervision and frequent supervisory observations of nursing staffs' administration of medications to facility residents, as a result of medication error involving Resident #1. Based on the above, the facility's administration failed to maintain a system that ensured the accurate administration of resident medication, in accordance with physician's orders [REDACTED].#1 when the resident received the narcotic [MEDICATION NAME] in the absence of a physician's orders [REDACTED]. The immediate jeopardy was determined to have been removed on 01/17/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: 1. On December 30, 2013, upon learning of the medication error involving Resident #1 from the resident's family, the DON immediately checked Resident #1's medications to ensure all medications were correctly labeled and packaged. Additionally, the charts and narcotic sign-out sheets of the two residents in the facility who received [MEDICATION NAME] per physicians' orders were reviewed. This audit revealed no discrepancies. 2. On December 30, 2013, the incident involving the [MEDICATION NAME] medication error was initially submitted to the members of the Quality Assurance (QA) Committee to make them aware. 3. On December 30, 2013, the facility initiated one-on-one inservice training with all nursing staff, conducted by the DON, related to the medication error involving Resident #1 and the facility's plan to correct and monitor the problem regarding medication administration. As of 01/16/2014 (the date of submission by the facility of the credible allegation of jeopardy removal), ten (10) nurses had received this in-service training. The five (5) remaining charge nurses, who had been unavailable for training due to being on leave or due to their part-time work status, will receive this in-service training on the date of their return to work. This procedure also specified that all newly-hired nursing staff would receive training on the facility's medication administration policies and procedures upon hire. 4. On December 30, 2013, the facility initiated a procedure by which the DON, ADON, Clinical Case Manager, and/or Pharmacy Consultant were to conduct medication pass audits with all nursing staff on a weekly basis utilizing the Medication Pass Observation Report form. These medication pass audits were to involve observation of each nurse on duty on a weekly basis, and were to continue for a minimum of six (6) months. As of 01/16/2014, seven (7) charge nurses had been observed, with the remaining eight (8) nursing staff, who had thus far been unavailable, to be observed on the date of their return to work. 5. On December 31, 2013, the Assistant Director of Nursing (ADON) and Patient Care Coordinator conducted a complete resident chart audit and medication cart audit. During this audit, no discrepancies were noted. 6. On December 31, 2013, the DON conducted an investigation into the medication error involving the administration of [MEDICATION NAME] to Resident #1. This investigation included a review of Resident #1's status during the period of time leading up to the hospital transfer of 12/26/2013, a consultation with a toxicologist regarding Resident #1's drug screen results related to the resident's significantly high [MEDICATION NAME] level, and a discussion of the medication error with the nursing staff who had been on duty from 7:00 a.m. on 12/25/2013 through 7:00 a.m. on 12/26/2013. 7. On January 12, 2014, all fifteen (15) facility nurses had watched the video series "Passing Medications...ASP's Medication Administration Part 1", and all had passed the post-test. 8. On January 16, 2014, the facility initiated a procedure by which both the DON and Patient Care Coordinator were to conduct a weekly medication cart audit utilizing the Medication Cart Audit Form. This medication cart audit assesses multiple criteria, including the accuracy of medication labels, the accuracy of resident Medication Administration Records, and the accuracy of the medication cart content related to resident medication. These weekly cart audits will occur on an ongoing basis. 9. On January 16, 2014, the facility initiated a procedure by which two (2) nurses would be required to sign-out [MEDICATION NAME] and observe administration of the medication. This procedure would be monitored by the DON or ADON Monday through Friday, and by the Registered Nurse supervisor on Saturday and Sunday. The supervisory staff monitoring would be documented utilizing the Daily [MEDICATION NAME] Compliance Form. The results of this monitoring, via this Form, will be reported by the DON to the QA Committee. 10. On January 16, 2014, the facility initiated a procedure by which the results of supervisory staffs' audits and monitoring of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted by the DON to the QA Committee on a quarterly basis, for evaluation and tracking by the QA Committee. The QA Committee will, based on the submitted data, evaluate the need for additional staff training and policy review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the significant medication error involving [MEDICATION NAME] administration, was removed on January 17, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had begun the process, initiated on 12/30/2013, of one-on-one nursing staff training regarding the facility's plan to address the significant medication error involving [MEDICATION NAME] administration. However, as of 01/16/2014 (the day prior to the 01/17/2014 exit date of this complaint survey), only ten (10) of the facility's fifteen (15) nurses had received this training, with the remaining nurses to receive training upon their return to work. Additionally, the facility had initiated a procedure, originally started on 12/30/2013, by which the facility administrative staff and/or the Pharmacy Consultant would conduct weekly medication pass audits involving the observation of each nurse to ensure accurate medication administration. As of 01/16/2014, (7) nurses had been observed, but eight (8) nursing staff would be unavailable for observation until they returned to work. Also, as part of the corrective plan, the facility initiated a procedure by which the results of supervisory staffs' audits of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report form, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted to the QA Committee on a quarterly basis for their review and evaluation. However, as of the 01/17/2014 exit date of this complaint survey, the QA Committee had not yet met to begin the process of evaluating facility nursing staffs' conformance with the facility's medication administration policies and procedures to ensure the accurate administration of resident medication. Thus, the QA Committee's ongoing process of procedural oversight, regarding accurate medication administration, could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, and hospital document review, the facility failed to have an effective Quality Assessment and Assurance Committee that developed and implemented a plan of action, and developed methods of monitoring the effect of implemented changes, in response to a significant medication error involving the administration of the narcotic [MEDICATION NAME] in the absence of a physician's orders [REDACTED]. Resident #1, who did not have a physician's orders [REDACTED]. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on January 15, 2014 at 2:55 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 25, 2013 (the date the facility concluded that Resident #1 received [MEDICATION NAME] in error), continued through January 16, 2014, and was removed on January 17, 2014. During an interview with the Administrator and DON conducted on January 16, 2014 at 12:30 p.m., the Administrator stated that after the incident involving Resident #1 receiving [MEDICATION NAME] in error, all members of the Quality Assurance (QA) Committee had been informed of the incident, but presented no evidence of the QA Committee's involvement in the formulation of, or involvement in, the corrective plan which was developed by the facility after this incident An allegation of jeopardy removal was received on January 16, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 17, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating nursing staffs' compliance with physicians' orders during medication administration, to ensure accurate medication administration, continued. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Observations were made of medication administration to residents to assess staffs' conformance with physicians' medication orders. Findings include: An interview was conducted with the Administrator on 01/16/2014 at 12:30 p.m. related to the facility's QA Committee and the Committee's oversight of resident medication administration. During this interview, the Administrator was questioned regarding the QA Committee's review of the medication error involving Resident #1 receiving [MEDICATION NAME] without having a physician's orders [REDACTED].#1, including actions initiated to allow nursing supervisory staff to monitor the effectiveness of the implemented corrective actions and procedural changes. The Administrator stated that all members of the QA Committee had been individually made aware of the medication error involving Resident #1, and had been informed of the corrective plan put into place by the facility in response to the incident. However, the Administrator further stated that the corrective plan which had been developed after Resident #1's [MEDICATION NAME] overdose had actually been formulated by herself, the DON, the ADON and the Pharmacy Consultant, and that there had been no meeting of the QA Committee since the 12/25/2013 incident to review the corrective plan. No evidence was presented to indicate that the QA Committee had conducted a review of the medication incident involving Resident #1 in an effort to evaluate the causal factor(s) of the incident. No evidence was presented to indicate that the QA Committee had reviewed, evaluated, or approved the corrective plan, which including procedural changes and which had been developed and implemented by facility administrative staff, to evaluate the effectiveness of the corrective actions in providing for consistent nursing staff compliance with the facility's medication administration policies and procedures. Additionally, no evidence was presented to show analysis by the QA Committee of the monitoring tools, such as the Med Cart Audit Form and the Daily [MEDICATION NAME] Compliance Form, developed as part of the corrective actions to ensure their effectiveness in monitoring ongoing compliance with medication administration in accordance with physicians' orders. The Administrator stated that next meeting of the QA Committee was scheduled to occur on January 29, 2014, and that this would be the first meeting of the QA Committee since the medication incident resulting in Resident #1 sustaining a [MEDICATION NAME] overdose. Cross refer to F333. The facility failed to provide medication administration in a manner to ensure that Resident #1 was free of a significant medication. Rather, Resident #1 received the narcotic [MEDICATION NAME] without having a physician's orders [REDACTED]. The immediate jeopardy was determined to have been removed on 01/17/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: 1. On December 30, 2013, upon learning of the medication error involving Resident #1 from the resident's family, the DON immediately checked Resident #1's medications to ensure all medications were correctly labeled and packaged. Additionally, the charts and narcotic sign-out sheets of the two residents in the facility who received [MEDICATION NAME] per physicians' orders were reviewed. This audit revealed no discrepancies. 2. On December 30, 2013, the incident involving the [MEDICATION NAME] medication error was initially submitted to the members of the Quality Assurance (QA) Committee to make them aware. 3. On December 30, 2013, the facility initiated one-on-one inservice training with all nursing staff, conducted by the DON, related to the medication error involving Resident #1 and facility's plan to correct and monitor the problem regarding medication administration. As of 01/16/2014 (the date of submission by the facility of the credible allegation of jeopardy removal), ten (10) nurses had received this in-service training. The five (5) remaining charge nurses, who had been unavailable for training due to being on leave or due to their part-time work status, will receive this in-service training on the date of their return to work. This procedure also specifies that all newly-hired nursing staff will receive training on the facility's medication administration policies and procedures upon hire. 4. On December 30, 2013, the facility initiated a procedure by which the DON, ADON, Clinical Case Manager, and/or Pharmacy Consultant were to conduct medication pass audits with all nursing staff on a weekly basis utilizing the Medication Pass Observation Report form. These medication pass audits were to involve observation of each nurse on duty on a weekly basis, and were to continue for a minimum of six (6) months. As of 01/16/2014, seven (7) charge nurses had been observed, with the remaining eight (8) nursing staff, who had thus far been unavailable, to be observed on the date of their return to work. 5. On December 31, 2013, the Assistant Director of Nursing (ADON) and Patient Care Coordinator conducted a complete resident chart audit and medication cart audit. During this audit, no discrepancies were noted. 6. On December 31, 2013, the DON conducted an investigation into the medication error involving the administration of [MEDICATION NAME] to Resident #1. This investigation included a review of Resident #1's status during the period of time leading up to the hospital transfer of 12/26/2013, a consultation with a toxicologist regarding Resident #1's drug screen results related to the resident's significantly high [MEDICATION NAME] level, and a discussion of the medication error with the nursing staff who had been on duty from 7:00 a.m. on 12/25/2013 through 7:00 a.m. on 12/26/2013. 7. On January 12, 2014, all fifteen (15) facility nurses had watched the video series "Passing Medications...ASP's Medication Administration Part 1", and all had passed the post-test. 8. On January 16, 2014, the facility initiated a procedure by which both the DON and Patient Care Coordinator were to conduct a weekly medication cart audit utilizing the Medication Cart Audit Form. This medication cart audit assesses multiple criteria, including the accuracy of medication labels, the accuracy of resident Medication Administration Records, and the accuracy of the medication cart content related to resident medication. These weekly cart audits will occur on an ongoing basis. 9. On January 16, 2014, the facility initiated a procedure by which two (2) nurses would be required to sign-out [MEDICATION NAME] and observe administration of the medication. This procedure would be monitored by the DON or ADON Monday through Friday, and by the Registered Nurse supervisor on Saturday and Sunday. The supervisory staff monitoring would be documented utilizing the Daily [MEDICATION NAME] Compliance Form. The results of this monitoring, via this Form, will be reported by the DON to the QA Committee. 10. On January 16, 2014, the facility initiated a procedure by which the results of supervisory staffs' audits and monitoring of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form, would be submitted by the DON to the QA Committee on a quarterly basis, for evaluation and tracking by the QA Committee. The QA Committee will, based on the submitted data, evaluate the need for additional staff training and policy review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the significant medication error involving [MEDICATION NAME] administration, was removed on January 17, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had begun the process, initiated on 12/30/2013, of one-on-one nursing staff training regarding the facility's plan to address the significant medication error involving [MEDICATION NAME] administration. However, as of 01/16/2014 (the day prior to the 01/17/2014 exit date of this complaint survey), only ten (10) of the facility's fifteen (15) nurses had received this training, with the remaining nurses to receive training upon their return to work. Additionally, the facility had initiated a procedure, originally started on 12/30/2013, by which the facility administrative staff and/or the Pharmacy Consultant would conduct weekly medication pass audits involving the observation of each nurse to ensure accurate medication administration. However, as of 01/16/2014, (7) nurses had been observed, but eight (8) nursing staff would be unavailable for observation until they returned to work. Also, as part of the corrective plan, the facility initiated a procedure by which the results of supervisory staffs' audits of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report form, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted to the QA Committee on a quarterly basis for their review and evaluation. However, as of the 01/17/2014 exit date of this complaint survey, the QA Committee had not yet met to begin the process of evaluating facility nursing staffs' conformance with the facility's medication administration policies and procedures to ensure the accurate administration of resident medication. Thus, the QA Committee's ongoing process of procedural oversight, regarding accurate medication administration, could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, hospital History and Physical Report review, hospital Drug Quick Screen review, hospital Discharge Summary review, Lexi-Comp Geriatric Dosage Handbook, 12th Edition review, and Facility Investigative report review, the facility failed to ensure the provision of care in a manner that prevented the neglect of one (1) resident (#1), who received the narcotic [MEDICATION NAME] in the absence of a physician's orders [REDACTED]. Resident #1 received [MEDICATION NAME] in error, with no order to receive the drug, and was then observed by staff to be unresponsive. Resident #1 was transported to the hospital where a toxicology screen revealed a toxic [MEDICATION NAME] level. Resident #1 was then admitted to the Intensive Care Unit and was administered a [MEDICATION NAME] drip as a narcotic overdose antidote, and also intravenous fluids. The facility's neglect of Resident #1, involving the administration of [MEDICATION NAME] to the resident in the absence of a physician's orders [REDACTED]. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on January 15, 2014 at 2:55 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 25, 2013 (the date the facility concluded that Resident #1 received [MEDICATION NAME] in error), continued through January 16, 2014, and was removed on January 17, 2014. During the January 15, 2014, 2:55 p.m. interview referenced above, the Administrator acknowledged the medication error involving Resident #1 receiving [MEDICATION NAME] without a physician's orders [REDACTED]. The Administrator stated that as a result of the August 2013 standard survey medication error citation, periodic medication pass observations had been conducted by supervisory staff, but also acknowledged the need for more supervision and more frequent observations of medication administration by facility nursing staff. An allegation of jeopardy removal was received on January 16, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 17, 2014, and the facility remained out of compliance at a lower scope and severity level of "D" while the process of evaluating nursing staffs' compliance with physicians' orders during medication administration, to ensure accurate medication administration, continued. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Observations were made of medication administration to residents to assess staffs' conformance with physicians' medication orders. Findings include: Record review for Resident #1 revealed a Minimum Data Set assessment of 11/08/2013 which documented in Section I-Active [DIAGNOSES REDACTED]. A Nurse's Notes (NN) entry of 12/26/2013 at 11:30 a.m. for Resident #1 documented that the resident would not respond or open his/her eyes and that, when contacted, the physician had ordered to send the resident to the hospital for evaluation. A 12/26/2013, 12:05 p.m. NN entry then documented Resident #1's transport to the hospital per this physician's orders [REDACTED]. The hospital History and Physical (H&P) referencing Resident #1's 12/26/2013 hospital admission documented a change in the resident's mental status, and documented that upon hospital arrival, the resident was somnolent and was noted to have pinpoint pupils. A dose of the narcotic antidote [MEDICATION NAME] was administered to Resident #1, and a toxicology screen completed in the emergency room revealed findings which included a large amount of [MEDICATION NAME] in the resident's system. This 12/26/2013 toxicology report, the emergency room Drug Quick Screen, for Resident #1 documented a toxic [MEDICATION NAME] level of 2023 nanograms/milliliter (ng/mL). (The Lexi-Comp Geriatric Dosage Handbook, 12th Edition, lists a [MEDICATION NAME] level greater than 2000 ng/mL as toxic.) Resident #1's hospital H&P referenced above, in addition to referencing the toxicology screen which had revealed a toxic [MEDICATION NAME] level of 2023 ng/mL, also documented in the Assessment Section that Resident #1 had "overdosed" on [MEDICATION NAME], and further documented Resident #1's admission to the Intensive Care Unit for the administration of a [MEDICATION NAME] drip and intravenous fluids. Resident #1's hospital Discharge Summary documented, in the Discharge [DIAGNOSES REDACTED]. Further review of Resident #1's clinical record revealed that, despite Resident #1 having been diagnosed at the hospital as having experienced a [MEDICATION NAME] overdose as indicated in the hospital H&P referenced above, there was no evidence to indicate that Resident #1 had a physician's orders [REDACTED]. In an Investigation Report (IR) completed by the facility as a result of an investigation into Resident #1's [MEDICATION NAME] overdose, the facility documented that a toxicologist, upon consultation, had stated that Resident #1's elevated [MEDICATION NAME] level was likely a peak level, occurring six to twelve hours after ingestion of the drug. This IR documented that based on the toxicologist's statement and on Resident #1's alertness until around 7:00 p.m. on 12/25/2013, the facility concluded that Resident #1's [MEDICATION NAME] medication error had occurred during the 12/25/2013, 8:00 p.m. to 9:00 p.m. medication pass. This IR further documented that the facility had found, via this investigation, that Resident #1 had received the 12/25/2013 bedtime medication which was ordered for, and intended for administration to, Resident #2. During an interview with the DON conducted on 01/14/2014 at 11:00 a.m. in reference to the incident involving Resident #1's [MEDICATION NAME] overdose, the DON acknowledged that Resident #1 did not have an order to receive [MEDICATION NAME], but stated that Resident #2, who resided on the same hall, did have an order for [REDACTED]." administered medications. Based on the above, the facility failed to provide care in a manner which prevented the neglect of Resident #1 by failing to ensure that the resident received only those medications ordered by the physician. Rather, Resident #1 received the narcotic [MEDICATION NAME] in the absence of a physician's orders [REDACTED]. Resident #1 was later found to be unresponsive and required hospital transfer and admission. A hospital toxicology screen revealed that Resident #1 had a toxic [MEDICATION NAME] level of 2023 ng/mL, requiring admission to the Intensive Care Unit and administration of a [MEDICATION NAME] drip and intravenous fluids for [DIAGNOSES REDACTED]. Cross refer to F333 for more information regarding Resident #1. The immediate jeopardy was determined to have been removed on 01/17/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: 1. On December 30, 2013, upon learning of the medication error involving Resident #1 from the resident's family, the DON immediately checked Resident #1's medications to ensure all medications were correctly labeled and packaged. Additionally, the charts and narcotic sign-out sheets of the two residents in the facility who received [MEDICATION NAME] per physicians' orders were reviewed. This audit revealed no discrepancies. 2. On December 30, 2013, the incident involving the [MEDICATION NAME] medication error was initially submitted to the members of the Quality Assurance (QA) Committee to make them aware. 3. On December 30, 2013, the facility initiated one-on-one inservice training with all nursing staff, conducted by the DON, related to the medication error involving Resident #1 and the facility's plan to correct and monitor the problem regarding medication administration. As of 01/16/2014 (the date of submission by the facility of the credible allegation of jeopardy removal), ten (10) nurses had received this in-service training. The five (5) remaining nurses, who had been unavailable for training due to being on leave or due to their part-time work status, will receive this in-service training on the date of their return to work. This procedure also specifies that all newly-hired nursing staff will receive training on the facility's medication administration policies and procedures upon hire. 4. On December 30, 2013, the facility initiated a procedure by which the DON, ADON, Clinical Case Manager, and/or Pharmacy Consultant were to conduct medication pass audits with all nursing staff on a weekly basis utilizing the Medication Pass Observation Report form. These medication pass audits were to involve observation of each nurse on duty on a weekly basis, and were to continue for a minimum of six (6) months. As of 01/16/2014, seven (7) charge nurses had been observed, with the remaining eight (8) nursing staff, who had thus far been unavailable, to be observed on the date of their return to work. 5. On December 31, 2013, the Assistant Director of Nursing (ADON) and Patient Care Coordinator conducted a complete resident chart audit and medication cart audit. During this audit, no discrepancies were noted. 6. On December 31, 2013, the DON conducted an investigation into the medication error involving the administration of [MEDICATION NAME] to Resident #1. This investigation included a review of Resident #1's status during the period of time leading up to the hospital transfer of 12/26/2013, a consultation with a toxicologist regarding Resident #1's drug screen results related to the resident's significantly high [MEDICATION NAME] level, and a discussion of the medication error with the nursing staff who had been on duty from 7:00 a.m. on 12/25/2013 through 7:00 a.m. on 12/26/2013. 7. On January 12, 2014, all fifteen (15) facility nurses had watched the video series "Passing Medications...ASP's Medication Administration Part 1", and all had passed the post-test. 8. On January 16, 2014, the facility initiated a procedure by which both the DON and Patient Care Coordinator were to conduct a medication cart audit utilizing the Medication Cart Audit Form. This medication cart audit assesses multiple criteria, including the accuracy of medication labels, the accuracy of resident Medication Administration Records, and the accuracy of the medication cart content related to resident medication. These weekly cart audits will occur on an ongoing basis. 9. On January 16, 2014, the facility initiated a procedure by which two (2) nurses would be required to sign-out [MEDICATION NAME] and observe administration of the medication. This procedure would be monitored by the DON or ADON Monday through Friday, and by the Registered Nurse supervisor on Saturday and Sunday. The supervisory staff monitoring would be documented utilizing the Daily [MEDICATION NAME] Compliance Form. The results of this monitoring, via this Form, will be reported by the DON to the QA Committee. 10. On January 16, 2014, the facility initiated a procedure by which the results of supervisory staffs' audits and monitoring of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form, would be submitted by the DON to the QA Committee on a quarterly basis, for evaluation and tracking by the QA Committee. The QA Committee will, based on the submitted data, evaluate the need for additional staff training and policy review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the significant medication error involving [MEDICATION NAME] administration, was removed on January 17, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had begun the process, initiated on 12/30/2013, of one-on-one nursing staff training regarding the facility's plan to address the significant medication error involving [MEDICATION NAME] administration. However, as of 01/16/2014 (the day prior to the 01/17/2014 exit date of this complaint survey), only ten (10) of the facility's fifteen (15) nurses had received this training, with the remaining nurses to receive training upon their return to work. Additionally, the facility had initiated a procedure, originally started on 12/30/2013, by which the facility administrative staff and/or the Pharmacy Consultant would conduct weekly medication pass audits involving the observation of each nurse to ensure accurate medication administration. As of 01/16/2014, (7) nurses had been observed, but eight (8) nursing staff would be unavailable for observation until they returned to work. Also, as part of the corrective plan, the facility initiated a procedure by which the results of supervisory staffs' audits of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report form, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted to the QA Committee on a quarterly basis for their review and evaluation. However, as of the 01/17/2014 exit date of this complaint survey, the QA Committee had not yet met to begin the process of evaluating facility nursing staffs' conformance with the facility's medication administration policies and procedures to ensure the accurate administration of resident medication. Thus, the QA Committee's ongoing process of procedural oversight, regarding accurate medication administration, could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the severity is reduced to the "D" level.

Based on clinical record review, staff interview, hospital History and Physical Report review, hospital Discharge Summary review, Facility Investigative report review, and review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, the facility failed to ensure that services were provided in accordance with professional standards of quality, regarding medication administration, for one (1) resident (#1) on the total survey sample of fifteen (15) residents. Resident #1 received the narcotic [MEDICATION NAME] without a physician's orders [REDACTED]. Resident #1 was determined, via a hospital laboratory test, to have a toxic [MEDICATION NAME] level, and was admitted to the Intensive Care Unit for receipt of a [MEDICATION NAME] drip for opioid overdose and intravenous fluids. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 15, 2014 at 2:55 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 25, 2013 (the date the facility concluded that Resident #1 received [MEDICATION NAME]), continued through January 16, 2014, and was removed on January 17, 2014. During an interview conducted on January 16, 2014 at 12:30 p.m., the Administrator acknowledged the significant medication error during which Resident #1 received [MEDICATION NAME]. The Administrator further stated that this medication error involving Resident #1 had required the facility to conduct thorough one-on-one training with nursing staff regarding the facility's medication administration policies and procedures. The Administrator also stated that the medication error had prompted the facility to initiate more frequent supervisory staff observations of nursing staff during the provision of resident medications to audit nursing staffs' accuracy during medication passes. An allegation of jeopardy removal was received on January 16, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 17, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating nursing staffs' compliance with physicians' orders during medication administration, to ensure accurate medication administration, continued. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Observations were made of medication administration to residents to assess staffs' conformance with physicians' medication orders. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that Chapter 2 - Standards of Nursing Practice, Section 2.2.2, Standards Related to Registered Nurse (RN) Responsibility for Nursing Practice Implementation, requires in Section 2.2.2(g) that the nurse implements treatment, including medication administration. Additionally, Section 2.3.2, Standards Related to Licensed Practical Nurse (LPN/VN) Responsibilities for Nursing Practice Implementation, requires in Section 2.3.2(i)(3) that the nurse administers medications accurately. Resident #1's Minimum Data Set of 11/08/2013 documented, in Section I-Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Further record review for Resident #1, to include review of the December 2013 Physicians' Orders, revealed no evidence to indicate that Resident #1 had a physician's orders [REDACTED]. A 12/26/2013, 11:30 a.m. Nurse's Notes (NN) entry documented Resident #1 to be unresponsive, with a physician's orders [REDACTED]. A 12/26/2013, 12:05 p.m. NN entry then documented Resident #1's hospital transfer. The hospital History and Physical (H&P) documented that, upon hospital arrival, Resident #1 was somnolent and had pinpoint pupils, for which [MEDICATION NAME] was administered. A toxicology screen revealed Resident #1 to have a large amount of [MEDICATION NAME] (2023 nanograms/milliliter) in his/her system. However, as referenced above, Resident #1's facility clinical record revealed no evidence of a physician's orders [REDACTED]. Despite that fact, the hospital H&P documented that Resident #1 had "overdosed" on [MEDICATION NAME] and was admitted to the Intensive Care Unit. The subsequent hospital Discharge Summary for Resident #1 documented [DIAGNOSES REDACTED]. In an Investigation Report (IR) referencing Resident #1's [MEDICATION NAME] overdose, the facility acknowledged a conclusion that on 12/25/2013, Resident #1 had received the medication of another resident (Resident #2) in error. This IR documented that, based on consultation with a toxicologist and a review of the emergence of Resident #1's altered level of consciousness on 12/26/2013, the facility concluded that the medication error involving [MEDICATION NAME] occurred during the 8:00 p.m. to 9:00 p.m. medication pass on 12/25/2013. The IR further documented that Nurse "CC", who was the Charge Nurse for the evening shift of 12/25/2013, was most likely the one who made the medication error. During an interview conducted on 01/14/2014 at 11:00 a.m., the DON acknowledged that Resident #1 had been determined to be positive for [MEDICATION NAME] when transferred to the hospital on [DATE], and also acknowledged that Resident #1 did not have a facility physician's orders [REDACTED].#1's onset of symptoms on 12/26/2013 and had concluded that on the evening of 12/25/2013, Resident #1 could have been given, in error, the [MEDICATION NAME] which was actually prescribed for Resident #2, who resided on the same hall as Resident #1. The DON stated that all facility nurses, including Nurse "CC", had been interviewed and none recalled making the medication error. However, the DON stated that based on the timeline involving the presentation of Resident #1's symptoms, disciplinary action had been taken against Nurse "CC", who was the Charge Nurse for the 3:00 p.m. - 11:00 p.m. shift of 12/25/2013, due to the conclusion that the medication error could have occurred on that date during that shift while Nurse "CC" administered medications. The DON also stated that the facility had not been able to determine if Nurse "CC" actually made the medication error, but acknowledged the occurrence of the medication error involving the mistaken administration of [MEDICATION NAME] to Resident #1 without a physician's orders [REDACTED]. Based on the above, the facility failed to ensure that Resident #1 received care in conformance with professional standards of quality, related to medication administration in accordance with physician's orders [REDACTED]. Resident #1 was then found unresponsive, was transported to the hospital, and was determined, via a toxicology screen, to have a toxic [MEDICATION NAME] level of 2023 nanograms/milliliter. Resident #1 was admitted to the Intensive Care Unit and received a [MEDICATION NAME] drip and intravenous fluids. Cross refer to F333 for more information regarding Resident #1. The immediate jeopardy was determined to have been removed on 01/17/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: 1. On December 30, 2013, upon learning of the medication error involving Resident #1 from the resident's family, the DON immediately checked Resident #1's medications to ensure all medications were correctly labeled and packaged. Additionally, the charts and narcotic sign-out sheets of the two residents in the facility who received [MEDICATION NAME] per physicians' orders were reviewed. This audit revealed no discrepancies. 2. On December 30, 2013, the incident involving the [MEDICATION NAME] medication error was initially submitted to the members of the Quality Assurance (QA) Committee to make them aware. 3. On December 30, 2013, the facility initiated one-on-one inservice training with all nursing staff, conducted by the DON, related to the medication error involving Resident #1 and the facility's plan to correct and monitor the problem regarding medication administration. As of 01/16/2014 (the date of submission by the facility of the credible allegation of jeopardy removal), ten (10) nurses had received this in-service training. The five (5) remaining nurses, who had been unavailable for training due to being on leave or due to their part-time work status, were to receive this in-service training on the date of their return to work. This procedure also specified that all newly-hired nursing staff would receive training on the facility's medication administration policies and procedures upon hire. 4. On December 30, 2013, the facility initiated a procedure by which the DON, ADON, Clinical Case Manager, and/or Pharmacy Consultant were to conduct medication pass audits with all nursing staff on a weekly basis utilizing the Medication Pass Observation Report form. These medication pass audits were to involve observation of each nurse on duty on a weekly basis, and were to continue for a minimum of six (6) months. As of 01/16/2014, seven (7) charge nurses had been observed, with the remaining eight (8) nursing staff, who had thus far been unavailable, to be observed on the date of their return to work. 5. On December 31, 2013, the Assistant Director of Nursing (ADON) and Patient Care Coordinator conducted a complete resident chart audit and medication cart audit. During this audit, no discrepancies were noted. 6. On December 31, 2013, the DON conducted an investigation into the medication error involving the administration of [MEDICATION NAME] to Resident #1. This investigation included a review of Resident #1's status during the period of time leading up to the hospital transfer of 12/26/2013, a consultation with a toxicologist regarding Resident #1's drug screen results related to the resident's significantly high [MEDICATION NAME] level, and a discussion of the medication error with the nursing staff who had been on duty from 7:00 a.m. on 12/25/2013 through 7:00 a.m. on 12/26/2013. 7. On January 12, 2014, all fifteen (15) facility nurses had watched the video series "Passing Medications...ASP's Medication Administration Part 1", and all had passed the post-test. 8. On January 16, 2014, the facility initiated a procedure by which both the DON and Patient Care Coordinator were to conduct a weekly medication cart audit utilizing the Medication Cart Audit Form. This medication cart audit assesses multiple criteria, including the accuracy of medication labels, the accuracy of resident Medication Administration Records, and the accuracy of the medication cart content related to resident medication. These weekly cart audits will occur on an ongoing basis. 9. On January 16, 2014, the facility initiated a procedure by which two (2) nurses would be required to sign-out [MEDICATION NAME] and observe administration of the medication. This procedure would be monitored by the DON or ADON Monday through Friday, and by the Registered Nurse supervisor on Saturday and Sunday. The supervisory staff monitoring would be documented utilizing the Daily [MEDICATION NAME] Compliance Form. The results of this monitoring, via this Form, will be reported by the DON to the QA Committee. 10. On January 16, 2014, the facility initiated a procedure by which the results of supervisory staffs' audits and monitoring of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form, would be submitted by the DON to the QA Committee on a quarterly basis, for evaluation and tracking by the QA Committee. The QA Committee will, based on the submitted data, evaluate the need for additional staff training and policy review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the significant medication error involving [MEDICATION NAME] administration, was removed on January 17, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had begun the process, initiated on 12/30/2013, of one-on-one nursing staff training regarding the facility's plan to address the significant medication error involving [MEDICATION NAME] administration. However, as of 01/16/2014 (the day prior to the 01/17/2014 exit date of this complaint survey), only ten (10) of the facility's fifteen (15) nurses had received this training, with the remaining nurses to receive training upon their return to work. Additionally, the facility had initiated a procedure, originally started on 12/30/2013, by which the facility administrative staff and/or the Pharmacy Consultant would conduct weekly medication pass audits involving the observation of each nurse to ensure accurate medication administration. As of 01/16/2014, (7) nurses had been observed, but eight (8) nursing staff would be unavailable for observation until they returned to work. Also, as part of the corrective plan, the facility initiated a procedure by which the results of supervisory staffs' audits of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report form, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted to the QA Committee on a quarterly basis for their review and evaluation. However, as of the 01/17/2014 exit date of this complaint survey, the QA Committee had not yet met to begin the process of evaluating facility nursing staffs' conformance with the facility's medication administration policies and procedures to ensure the accurate administration of resident medication. Thus, the QA Committee's ongoing process of procedural oversight, regarding accurate medication administration, could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, hospital History and Physical Report review, hospital Drug Quick Screen review, hospital Discharge Summary review, Lexi-Comp Geriatric Dosage Handbook, 12th Edition review, and Facility Investigative report review, the facility failed to provide care, related to medication administration as per physician's orders [REDACTED].#1) on the total survey sample of fifteen (15) residents. For Resident #1, whose Care Plan noted the use of multiple medications including [MEDICATION NAME] ER, [MEDICATION NAME] XL, [MEDICATION NAME], and Tylenol per physician's orders [REDACTED]. An emergency room toxicology screen revealed a toxic level of [MEDICATION NAME] in Resident #1's system, even though the resident did not have a physician's orders [REDACTED]. This failure of the facility to administer to Resident #1 only those medications which were ordered, to avoid adverse effects from medications as specified by the Care Plan, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 15, 2014 at 2:55 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on December 25, 2013 (the date the facility concluded that Resident #1 received [MEDICATION NAME] in error), continued through January 16, 2014, and was removed on January 17, 2014. During an interview with the DON which had been conducted on January 14, 2014 at 11:00 a.m., the DON acknowledged the medication error in which Resident #1 received [MEDICATION NAME] in the absence of a physician's orders [REDACTED]. The DON further acknowledged that, due to this error, it had been necessary for the facility to make multiple corrective actions, including nursing staff retraining on medication administration and supervisory staff monitoring of nursing staffs' administration of medications during medication passes. An allegation of jeopardy removal was received on January 16, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on January 17, 2014, and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating nursing staffs' compliance with physicians' orders during medication administration, to ensure accurate medication administration, continued. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Observations were made of medication administration to residents to assess staffs' conformance with physicians' medication orders. Findings include: Record review for Resident #1 revealed a Minimum Data Set assessment of 11/08/2013 which documented, in Section I-Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Further review of Resident #1's clinical record revealed that the current Physician order [REDACTED].) at bedtime for Generalized Pain. Additional record review for Resident #1, to include review of this current Physician order [REDACTED]. Review of Resident #1's Care Plan revealed multiple identified Problems involving the administration of drug therapy, and specifying as Current Approaches that drug therapy be administered in accordance with physician's orders [REDACTED].#1 would have no adverse effects from medication. Resident #1's Care Plan also identified, as another Problem, that Resident #1 was being treated for [REDACTED]. [REDACTED]. A 12/26/2013, 11:30 a.m. Nurse's Notes (NN) entry for Resident #1 documented that the resident would not respond or open the eyes, and documented that an order was received to send the resident to the hospital. The hospital History and Physical (H&P) report documented that, upon arrival at the hospital, Resident #1 was somnolent and had pinpoint pupils. A Drug Quick Screen for Resident #1 then revealed a toxic level of 2023 nanograms/milliliters (ng/mL) of [MEDICATION NAME] in the resident's system. (A [MEDICATION NAME] level greater than 2000 ng/mL was toxic, per the Lexi-Comp Geriatric Dosage Handbook, 12th Edition). This was despite the fact that, as referenced above, there was no nursing facility physician's orders [REDACTED]. Resident #1's hospital H&P referenced above documented that multiple doses of the opiate overdose antidote [MEDICATION NAME] were administered for the toxic level of [MEDICATION NAME] related to a [MEDICATION NAME] overdose, and documented that Resident #1 would be admitted to the Intensive Care Unit for administration of a [MEDICATION NAME] drip and intravenous fluids. The hospital Discharge Summary for Resident #1 documented [DIAGNOSES REDACTED]. A facility Investigation Report (IR) for Resident #1 referenced the [MEDICATION NAME] overdose, as indicated by the hospital drug screen revealing a toxic level of [MEDICATION NAME]. The IR documented that the facility's investigation found that on 12/25/2013, Resident #1 received another resident's medication. This IR documented that during the facility's investigation, which included consultation with a laboratory toxicologist, the facility concluded that the medication error involving Resident #1 receiving [MEDICATION NAME] had occurred during the 8:00 p.m. to 9:00 p.m. medication pass of 12/25/2013. During a 01/14/2014, 11:00 a.m. interview, the DON acknowledged that Resident #1's hospital drug screen had revealed a positive [MEDICATION NAME] result, but further acknowledged that Resident #1 did not have an order to receive [MEDICATION NAME]. The DON also acknowledged the facility's conclusion, as referenced in the IR above, that Resident #1 could have received [MEDICATION NAME] that was prescribed for Resident #2 on 12/25/2013. Based on the above, even though the Care Plan of Resident #1 specified that the resident would receive medications as per physician's orders [REDACTED].#1 did not have a physician's orders [REDACTED]. Resident #1 was then noted to be unresponsive and was transported to the hospital where he/she was observed to be somnolent with pinpoint pupils. A toxicology screen revealed a toxic [MEDICATION NAME] level of 2023 ng/mL, and Resident #1 was admitted to the Intensive Care Unit and received a [MEDICATION NAME] drip and intravenous fluids for [DIAGNOSES REDACTED]. The facility thus failed to ensure the administration of medications per physician's orders [REDACTED].#1, also as specified by the Care Plan. Cross refer to F333 for more information regarding Resident #1. The immediate jeopardy was determined to have been removed on 01/17/2014, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: 1. On December 30, 2013, upon learning of the medication error involving Resident #1 from the resident's family, the DON immediately checked Resident #1's medications to ensure all medications were correctly labeled and packaged. Additionally, the charts and narcotic sign-out sheets of the two residents in the facility who received [MEDICATION NAME] per physicians' orders were reviewed. This audit revealed no discrepancies. 2. On December 30, 2013, the incident involving the [MEDICATION NAME] medication error was initially submitted to the members of the Quality Assurance (QA) Committee to make them aware. 3. On December 30, 2013, the facility initiated one-on-one inservice training with all nursing staff, conducted by the DON, related to the medication error involving Resident #1 and facility's plan to correct and monitor the problem regarding medication administration. As of 01/16/2014 (the date of submission by the facility of the credible allegation of jeopardy removal), ten (10) nurses had received this in-service training. The five (5) remaining charge nurses, who had been unavailable for training due to being on leave or due to their part-time work status, will receive this in-service training on the date of their return to work. This procedure also specified that all newly-hired nursing staff will receive training on the facility's medication administration policies and procedures upon hire. 4. On December 30, 2013, the facility initiated a procedure by which the DON, ADON, Clinical Case Manager, and/or Pharmacy Consultant were to conduct medication pass audits with all nursing staff on a weekly basis utilizing the Medication Pass Observation Report form. These medication pass audits were to involve observation of each nurse on duty on a weekly basis, and were to continue for a minimum of six (6) months. As of 01/16/2014, seven (7) charge nurses had been observed, with the remaining eight (8) nursing staff, who had thus far been unavailable, to be observed on the date of their return to work. 5. On December 31, 2013, the ADON and Patient Care Coordinator conducted a complete resident chart audit and medication cart audit. During this audit, no discrepancies were noted. 6. On December 31, 2013, the DON conducted an investigation into the medication error involving the administration of [MEDICATION NAME] to Resident #1. This investigation included a review of Resident #1's status during the period of time leading up to the hospital transfer of 12/26/2013, a consultation with a toxicologist regarding Resident #1's drug screen results related to the resident's significantly high [MEDICATION NAME] level, and a discussion of the medication error with the nursing staff who had been on duty from 7:00 a.m. on 12/25/2013 through 7:00 a.m. on 12/26/2013. 7. On January 12, 2014, all fifteen (15) facility nurses had watched the video series "Passing Medications...ASP's Medication Administration Part 1", and all had passed the post-test. 8. On January 16, 2014, the facility initiated a procedure by which both the DON and Patient Care Coordinator were to conduct weekly medication cart audits utilizing the Medication Cart Audit Form. This medication cart audit assesses multiple criteria, including the accuracy of medication labels, the accuracy of resident Medication Administration Records, and the accuracy of medication cart content related to resident medication. These weekly cart audits will occur on an ongoing basis. 9. On January 16, 2014, the facility initiated a procedure by which two (2) nurses would be required to sign-out [MEDICATION NAME] and observe administration of the medication. This procedure would be monitored by the DON or ADON Monday through Friday, and by the Registered Nurse supervisor on Saturday and Sunday. The supervisory staff monitoring would be documented utilizing the Daily [MEDICATION NAME] Compliance Form. The results of this monitoring, via this Form, will be reported by the DON to the QA Committee. 10. On January 16, 2014, the facility initiated a procedure by which the results of supervisory staffs' audits and monitoring of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted by the DON to the QA Committee on a quarterly basis, for evaluation and tracking by the QA Committee. The QA Committee will, based on the submitted data, evaluate the need for additional staff training and policy review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the significant medication error involving [MEDICATION NAME] administration, was removed on January 17, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had begun the process, initiated on 12/30/2013, of one-on-one nursing staff training regarding the facility's plan to address the significant medication error involving [MEDICATION NAME] administration. However, as of 01/16/2014 (the day prior to the 01/17/2014 exit date of this complaint survey), only ten (10) of the facility's fifteen (15) nurses had received this training, with the remaining nurses to receive training upon their return to work. Additionally, the facility had initiated a procedure, originally started on 12/30/2013, by which the facility administrative staff and/or the Pharmacy Consultant would conduct weekly medication pass audits involving the observation of each nurse to ensure accurate medication administration. As of 01/16/2014, (7) nurses had been observed, but eight (8) nursing staff would be unavailable for observation until they returned to work. Also, as part of the corrective plan, the facility initiated a procedure by which the results of supervisory staffs' audits of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report form, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted to the QA Committee on a quarterly basis for their review and evaluation. However, as of the 01/17/2014 exit date of this complaint survey, the QA Committee had not yet met to begin the process of evaluating facility nursing staffs' conformance with the facility's medication administration policies and procedures to ensure the accurate administration of resident medication. Thus, the QA Committee's ongoing process of procedural oversight, regarding accurate medication administration, could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on clinical record review, staff interview, Poison Control Center pharmacist interview, SBAR Communication Form/Progress Note review, hospital History and Physical Report review, hospital Drug Quick Screen review, hospital Discharge Summary review, Lexi-Comp Geriatric Dosage Handbook, 12th Edition review, and Facility Investigative report review, the facility failed to ensure that one (1) resident (#1) was free of a significant medication error, regarding the administration of the narcotic [MEDICATION NAME], on the total survey sample of fifteen (15) residents. Resident #1, who did not have a physician's order for the administration of [MEDICATION NAME], received [MEDICATION NAME] in error. Subsequently, Resident #1 was observed by facility staff to be unresponsive to verbal or painful stimuli, and was transported via Emergency Medical Service to the hospital where he/she was noted with somnolence and to have pinpoint pupils. An emergency room toxicology screen for Resident #1 revealed a toxic [MEDICATION NAME] level, and thus the resident was admitted to the Intensive Care Unit and received a [MEDICATION NAME] drip, as an opioid overdose antidote, and also intravenous fluids for a [DIAGNOSES REDACTED]. This significant medication error involving the administration of [MEDICATION NAME] to Resident #1, with no physician's order for administration, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 2:55 p.m. The non-compliance related to the immediate jeopardy was identified to have existed on [DATE] (the date the facility concluded that Resident #1 received [MEDICATION NAME] in error), continued through [DATE], and was removed on [DATE]. During the [DATE], 2:55 p.m. interview referenced above, the Administrator acknowledged the medication error involving Resident #1 having received [MEDICATION NAME]. During a later interview conducted on [DATE] at 12:30 p.m., the Administrator also acknowledged awareness of the facility being cited for having a medication error rate which exceeded five (5) percent during the standard survey of [DATE]. The Administrator stated that as a result of the [DATE] standard survey citation involving medication errors, periodic medication pass observations had been conducted by supervisory staff to audit medication administration, but further acknowledged the need for more supervision and frequent supervisory observations related to medication administration to facility residents. An allegation of jeopardy removal was received on [DATE]. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on [DATE], and the facility remained out of compliance at a lower scope and severity of "D" while the process of evaluating nursing staffs' compliance with physicians' orders during medication administration, to ensure accurate medication administration, continued. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Observations were made of medication administration to residents to assess staffs' conformance with physicians' medication orders. Findings include: Record review for Resident #1 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of [DATE] which documented that the resident's year of birth was 1927, thus indicating the resident was [AGE] years of age. Section I-Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #1 was totally dependent on staff for transfer and for ambulation/locomotion. A Nurse's Notes (NN) entry of [DATE] at 10:00 a.m. for Resident #1 documented that the resident was lethargic, but that he/she would open his/her eyes. This NN documented that the physician was notified. A NN entry of [DATE] at 11:30 a.m. documented that by that time, staff was unable to get Resident #1 to respond at all, and that the resident would not open his/her eyes at that point. This NN documented that a physician's order was received to send Resident #1 to the hospital emergency room (ER) for evaluation and treatment. A facility SBAR Communication Form and Progress Note which referenced Resident #1 also documented the [DATE] physician notification and order for hospital transfer, and documented that the resident was not responding to either verbal or painful stimuli and would not open his/her eyes. A NN entry of [DATE] at 12:05 p.m. for Resident #1 documented that the resident had been transported to the hospital via Emergency Medical Service, per the physician's order referenced above. A hospital History and Physical (H&P) report for Resident #1 documented the resident's [DATE] admission to the hospital. This H&P documented, in the Chief Complaint section, that the resident had experienced a change in mental status. The History of Present Illness section of the H&P documented that upon arrival at the hospital, the resident was somnolent and was noted to have pinpoint pupils, for which a 0.4 milligram (mg) dose of [MEDICATION NAME] was administered. This section of the H&P documented that the resident's response to the dose of [MEDICATION NAME] prompted a toxicology screen, which revealed findings including a large amount of [MEDICATION NAME] following repeated dilution. Review of the toxicology screen, the hospital Drug Quick Screen, referenced above for Resident #1, dated and timed as having been collected on [DATE] at 12:57 p.m., documented that the [MEDICATION NAME] screen for the resident had revealed a result of 2023 nanograms/milliliter (ng/mL). The Lexi-Comp Geriatric Dosage Handbook, 12th Edition, indicated that a [MEDICATION NAME] level of greater than 2000 ng/mL was toxic. The hospital H&P referenced above for Resident #1 documented that the resident again became somnolent in the ER after the initial dose of [MEDICATION NAME], requiring the administration of another dose of [MEDICATION NAME], and thus Resident #1 was admitted to the hospital. The Labs section of this H&P referenced the toxicology screen of Resident #1 revealing an elevated [MEDICATION NAME] level of 2023 ug/mL, with the Assessment section of the H&P documenting that the resident had "definitely overdosed" on [MEDICATION NAME]. The Plan section of the H&P indicated that Resident #1 would be admitted to the hospital Intensive Care Unit, where he/she would receive a [MEDICATION NAME] drip and intravenous fluids. The hospital Discharge Summary for Resident #1 documented a hospital discharge date of [DATE]. The Hospital Course section of this Discharge Summary documented that while in the hospital, Resident #1 had begun to return to his/her baseline in terms of mentation, and that he/she was awake and interacting appropriately. The Discharge [DIAGNOSES REDACTED]. Review of Resident #1's nursing facility clinical record revealed an Entry MDS of [DATE] which documented that the resident had been readmitted to the nursing facility from the hospital. However, further record review for Resident #1, to include review of the resident's monthly [DATE] Physicians' Orders form which had been effect prior to the resident's [DATE] hospital transfer, revealed no evidence to indicate that Resident #1 had a physician's order to receive [MEDICATION NAME]. Additional record review, to include review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This was despite the fact that, as indicated in the hospital H&P and Discharge Summary referenced above, Resident #1 had been transferred from the nursing facility to the hospital on [DATE] after a significant change in mental status and had been determined to have an overdose of [MEDICATION NAME], with a toxic [MEDICATION NAME] level of 2023 ug/mL. During an interview with the DON conducted on [DATE] at 11:00 a.m., the DON was asked about Resident #1's hospital transfer and [MEDICATION NAME] overdose. The DON acknowledged that Resident #1 had been transferred to the hospital on [DATE] after a nurse had noted the resident to have a decreased level of consciousness. The DON further acknowledged that the drug screen performed at the hospital had revealed Resident #1 to be positive for [MEDICATION NAME]. The DON also stated that, although Resident #1 did not have an order to receive [MEDICATION NAME], another facility resident (Resident #2) who resided on the same hall as Resident #1 did receive [MEDICATION NAME] per a physician's order. Record review for Resident #2 revealed that this resident did reside on the same unit and hall as Resident #1. Further record review revealed that Resident #2 had a current physician's order, originally dating from [DATE], specifying that the resident receive a dose of four (4) 10 mg. [MEDICATION NAME] tablets, yielding a forty (40) mg. dose, by mouth three times daily, at 9:00 a.m., 2:00 p.m. and 9:00 p.m. The facility presented an Investigation Report (IR) related to the facility's investigation into Resident #1's significant medication error involving [MEDICATION NAME] and resulting in the [MEDICATION NAME] overdose. In this IR, the facility documented that, based on its investigation, it was found that on [DATE], Resident #1 had received the bedtime medication of another resident (Resident #2) who resided on the same hall as Resident #1, and two (2) doors down from Resident #1. The IR documented that this finding was based on information received from consultation with a laboratory toxicologist. The IR documented the toxicologist had stated that due to [MEDICATION NAME]'s specific and synthetic nature, Resident #1's hospital Drug Quick Screen laboratory test which revealed an elevated level of [MEDICATION NAME] would have been accurate for the presence of [MEDICATION NAME]. The toxicologist stated that the significantly high [MEDICATION NAME] level likely indicated that this was a peak level of the drug which would have occurred six (6) to twelve (12) hours after ingestion, and that [MEDICATION NAME] would not have shown in Resident #1's drug screen 72 hours after ingestion. This IR documented that, based on the toxicologist's statement regarding the peak [MEDICATION NAME] level indicated by the drug screen, and based on Resident #1's unaltered level of consciousness up until approximately 7:00 p.m. on [DATE] (the evening before Resident #1's subsequent [DATE] hospital transfer related to an altered level of consciousness) as reflected by the resident's meal intake, reports from staff, and family observations, the facility concluded that the medication error involving Resident #1 receiving [MEDICATION NAME] occurred during the 8:00 p.m. to 9:00 p.m. medication pass on [DATE]. During the [DATE], 11:00 a.m. DON interview referenced above, the DON acknowledged that, as the facility evaluated the onset of Resident #1's symptoms on [DATE], the facility had concluded after investigation that Resident #1 could have been given the [MEDICATION NAME] (actually prescribed for Resident #2) in error the prior evening of [DATE]. The DON further stated that in evaluating the timeline of Resident #1's development of symptoms, the facility had concluded that the medication error could have occurred on the 3:00 p.m.-11:00 p.m. shift of [DATE]. On [DATE] at 4:30 p.m., a telephone interview was conducted with a pharmacist from the Poison Control Center. During this interview, this pharmacist was questioned regarding [MEDICATION NAME] dosing and the toxicity level of the drug. She stated that if a person who was not accustomed to receiving [MEDICATION NAME] were to receive a single 40 mg dose of the drug, the person would at the very least become significantly sedated. She stated that a drug screen revealing a [MEDICATION NAME] level of 2023 ng/mL, as reflected on Resident #1's Drug Quick Screen, would indicate that the person received at least 40 mgs of [MEDICATION NAME], and potentially more, and further stated that the person could have possibly died with a toxic [MEDICATION NAME] level of 2023 ng/mL in his/her system. Based on the above, despite the absence of a physician's order for the administration of [MEDICATION NAME] to Resident #1, Resident #1 experienced a significant medication error by receiving [MEDICATION NAME] in error. Resident #1 was later noted by staff to be unresponsive and was transported to the hospital ER. In the ER, Resident #1 was noted to be somnolent and to have pinpoint pupils, resulting in the administration of [MEDICATION NAME]. An ER toxicology screen then revealed a toxic [MEDICATION NAME] level of 2023 ng/mL, requiring the administration additional [MEDICATION NAME], admission to the hospital Intensive Care Unit, and the administration of a [MEDICATION NAME] drip and intravenous fluids for a [DIAGNOSES REDACTED]. The immediate jeopardy was determined to have been removed on [DATE], at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: 1. On [DATE], upon learning of the medication error involving Resident #1 from the resident's family, the DON immediately checked Resident #1's medications to ensure all medications were correctly labeled and packaged. Additionally, the charts and narcotic sign-out sheets of the two residents in the facility who received [MEDICATION NAME] per physicians' orders were reviewed. This audit revealed no discrepancies. 2. On [DATE], the incident involving the [MEDICATION NAME] medication error was initially submitted to the members of the Quality Assurance (QA) Committee to make them aware. 3. On [DATE], the facility initiated one-on-one inservice training with all nursing staff, conducted by the DON, related to the medication error involving Resident #1 and the facility's plan to correct and monitor the problem regarding medication administration. As of [DATE] (the date of submission by the facility of the credible allegation of jeopardy removal), ten (10) nurses had received this in-service training. The five (5) remaining nurses, who had been unavailable for training due to being on leave or due to their part-time work status, were to receive this in-service training on the date of their return to work. This procedure also specified that all newly-hired nursing staff would receive training on the facility's medication administration policies and procedures upon hire. 4. On [DATE], the facility initiated a procedure by which the DON, ADON, Clinical Case Manager, and/or Pharmacy Consultant were to conduct medication pass audits with all nursing staff on a weekly basis utilizing the Medication Pass Observation Report form. These medication pass audits were to involve observation of each nurse on duty on a weekly basis, and were to continue for a minimum of six (6) months. As of [DATE], seven (7) charge nurses had been observed, with the remaining eight (8) nursing staff, who had thus far been unavailable, to be observed on the date of their return to work. 5. On [DATE], the Assistant Director of Nursing (ADON) and Patient Care Coordinator conducted a complete resident chart audit and medication cart audit. During this audit, no discrepancies were noted. 6. On [DATE], the DON conducted an investigation into the medication error involving the administration of [MEDICATION NAME] to Resident #1. This investigation included a review of Resident #1's status during the period of time leading up to the hospital transfer of [DATE], a consultation with a toxicologist regarding Resident #1's drug screen results related to the resident's significantly high [MEDICATION NAME] level, and a discussion of the medication error with the nursing staff who had been on duty from 7:00 a.m. on [DATE] through 7:00 a.m. on [DATE]. 7. On [DATE], all fifteen (15) facility nurses had watched the video series "Passing Medications...ASP's Medication Administration Part 1", and all had passed the post-test. 8. On [DATE], the facility initiated a procedure by which both the DON and Patient Care Coordinator were to conduct a weekly medication cart audit utilizing the Medication Cart Audit Form. This medication cart audit assesses multiple criteria, including the accuracy of medication labels, the accuracy of resident Medication Administration Records, and the accuracy of the medication cart content related to resident medication. These weekly cart audits will occur on an ongoing basis. 9. On [DATE], the facility initiated a procedure by which two (2) nurses would be required to sign-out [MEDICATION NAME] and observe administration of the medication. This procedure would be monitored by the DON or ADON Monday through Friday, and by the Registered Nurse supervisor on Saturday and Sunday. The supervisory staff monitoring would be documented utilizing the Daily [MEDICATION NAME] Compliance Form. The results of this monitoring, via this Form, will be reported by the DON to the QA Committee. 10. On [DATE], the facility initiated a procedure by which the results of supervisory staffs' audits and monitoring of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form, would be submitted by the DON to the QA Committee on a quarterly basis, for evaluation and tracking by the QA Committee. The QA Committee will, based on the submitted data, evaluate the need for additional staff training and policy review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice, related to the significant medication error involving [MEDICATION NAME] administration, was removed on [DATE]. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. The facility had begun the process, initiated on [DATE], of one-on-one nursing staff training regarding the facility's plan to address the significant medication error involving [MEDICATION NAME] administration. However, as of [DATE] (the day prior to the [DATE] exit date of this complaint survey), only ten (10) of the facility's fifteen (15) nurses had received this training, with the remaining nurses to receive training upon their return to work. Additionally, the facility had initiated a procedure, originally started on [DATE], by which the facility administrative staff and/or the Pharmacy Consultant would conduct weekly medication pass audits involving the observation of each nurse to ensure accurate medication administration. As of [DATE], (7) nurses had been observed, but eight (8) nursing staff would be unavailable for observation until they returned to work. Also, as part of the corrective plan, the facility initiated a procedure by which the results of supervisory staffs' audits of staff conformance with the facility's medication administration policies and procedures, via the Medication Pass Observation Report form, Medication Cart Audit Form, and Daily [MEDICATION NAME] Compliance Form would be submitted to the QA Committee on a quarterly basis for their review and evaluation. However, as of the [DATE] exit date of this complaint survey, the QA Committee had not yet met to begin the process of evaluating facility nursing staffs' conformance with the facility's medication administration policies and procedures to ensure the accurate administration of resident medication. Thus, the QA Committee's ongoing process of procedural oversight, regarding accurate medication administration, could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the "D" level.

Based on record review, staff and resident interviews, the facility failed to provide care in a manner that promoted privacy for one (1) resident ("R") from a sample of thirty-one (31) residents. This failure resulted in actual emotional harm to the resident. Findings include; Interview on 08/13/2013 at 11:11 a.m. with resident "R" revealed that the resident complained that she had been left lying in the bed for approximately fifteen (15) minutes exposed from the waist down while a Certified Nursing Assistant went to get a sit to stand lift to assist the resident to the bed side commode. Continued interview revealed that the resident could not get to the bed linens to cover herself and only had a yellow sleeveless shirt on. Further interview on 8/14/13 at 8:30 a.m. revealed that the door to the room was completely open. The resident stated that this made her angry and that it made her feel "just awful" that she was left lying in the bed naked from the waist down with the door open. Review of the clinical record for resident "R" revealed that the resident had multiple [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated 5/7/13 revealed that the resident was assessed with [REDACTED]. Continued review of the MDS assessment revealed that the resident was assessed as needing extensive assist with transfers, bed mobility, and all activities of daily living (ADLs), and was frequently incontinent of bladder. Interview on 8/13/13 at 9:43 a.m. with the Director of Nursing (DON) revealed that that it was definitely not acceptable for a staff member to leave a resident exposed and go out of the room with the door open. Continued interview revealed that the resident did talk with the DON after the conversation with the surveyor and expressed that the incident caused her to have a high level of anxiety. During an additional interview on 8/15/13 9:32 a.m. with resident "R", she stated that the situation was "emotionally harmful to me" and I should have never been left in a situation that caused so much stress. Cross refer to F241, example 2, for more information regarding Resident R.

Based on record review, staff interview, resident interview, and observation the facility failed to provide care and services to promote dignity and respect for two (2) residents ("R" and "T") from a sample of thirty-one (31) residents. This failure caused emotional harm to these residents. Findings include: 1. Observation on 8/14/13 at 7:45 a.m. revealed that resident "T" was seated on the bedside commode. Continued observation revealed that while the resident was on the commode, exposed from the waist down, Licensed Practical Nurse (LPN) "AA" was administering medication through the resident's enteral feeding tube. The resident also had a blood pressure cuff applied to one arm. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed with [REDACTED]. Continued review of the MDS assessment revealed that the resident was assessed as needing extensive assist with transfer, bed mobility, and activities of daily living (ADLs), and assessed as frequently incontinent of bowel and bladder. Interview with staff LPN "AA" at 8/13/13 at 12:45 p.m. revealed that she was aware that she should not have given medications via the [DEVICE] while the resident was seated on the bedside commode. Continued interview revealed that this was disrespectful of the resident. Interview with resident "T" on 8/14/13 at 4:10 p.m. revealed that the resident was tearful during the interview, stating that "the nurse giving me medications through the feeding tube while I was on the bedside commode made me feel bad." Interview with the Director of Nursing on 8/15/13 at 9:43 a.m. revealed that this incident should not have happened. Continued interview revealed that the resident should be in bed while giving medications through the enteral feeding tube with the head of the bed elevated and should be allowed to use the bathroom first. 2. Interview on 08/13/2013 at 11:11 a.m. with resident "R" revealed that the staff usually get her up to the bedside commode for bowel elimination but last night (8/12/13) she was told to get on the bed pan. The resident stated that she has a difficult time using a bed pan and really wanted to get up to the bedside commode. Continued interview revealed that the Certified Nursing Assistant (CNA) "FF" told the resident that they do not use the sit-and-stand lift at night for anything other than an emergency. The CNA did go to get the lift but left the resident laying in the bed for about fifteen (15) minutes, naked from the waist down and exposed, with the room door open. Further interview revealed that the resident said that it made her feel "just awful" that she was left laying in the bed, exposed while the CNA went to get the lift. "It was awful because I could not get the cover to cover myself. All I had on was this yellow sleeveless shirt. It was just awful". Review of the clinical record for resident "R" revealed that the resident had multiple [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated 5/7/13 revealed that the resident was assessed with [REDACTED]. Continued review of the MDS assessment revealed that the resident was assessed as needing extensive assist with transfers, bed mobility, and all activities of daily living (ADLs), and was frequently incontinent of bladder. Interview with the Director of Nursing on 8/13/13 at 9:43 a.m. revealed that it was not acceptable for a staff member to leave a resident exposed. Continued interview revealed the resident did express, to her, that the incident that happened Monday evening 8/12/13 did cause her to have a high level of anxiety. During an interview on 8/15/13 9:32 a.m. with resident "R", she stated that the situation was "emotionally harmful to me" and "I should have never been left in a situation that caused so much stress."

Based on observation, review of the Georgia Practical Nurse Act and staff interview, the facility failed to follow the standards of practice related to dignity during medication administration for one (1) resident ("T") from a sample of thirty-one (31) residents. This failure resulted in emotional harm to resident "T". Findings include: Observation on 08/14/13 at 07:45 a.m. revealed resident "T" seated on the bedside commode naked from the waist down. Continued observation revealed Licensed Practical Nurse (LPN) "AA" administering medication through a enteral feeding tube while the resident was on the bedside commode. During interview with resident "T" on 8/14/13 at 4:10 p.m., she stating that this incident "made me feel bad." This resident was observed to be tearful during this interview. Interview with LPN "AA" on 8/13/13 at 12:45 p.m. revealed that she should not have administered the resident's medication while the resident was seated on the bedside commode, and that she should have had more respect for the resident. Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation related to the maintenance of health and prevention of illness which shall include but not be limited to: -Section 2.3.2 Standards related to Licensed Practical Nurse, Subsection O Respects client's rights, concerns, decisions and dignity. Cross refer to F241, example 1, for more information regarding resident "T".