Every finding on record at The Ellington

Based on observations, interviews, and record reviews, the facility failed to ensure controlled substance medications were reconciled and accurately documented for 2 (#71, and #89) of 24 residents reviewed for accuracy of narcotic medication counts.Findings:A review of the facility's policy titled, Pharmacy Policy and Procedure Manual, with a last review date of 07/20/2026, read in part, The State Board of Pharmacy has established distinct regulations regarding the handling by DEA (Drug Enforcement Agency Schedules or Controlled Medication), medications in. nursing homes . in the state. In order to adhere to these regulations the following procedure was developed. Procedure. 6. Nurses shall complete all portions of the control sheets (proof of use) as medications are administered. On 08/11/2026 at 12:35 p.m., a controlled substance medication count and interview was conducted with S3LPN. The individual resident narcotic records and blister packs were reviewed and revealed the following controlled substance count discrepancies: -Resident #71's individual patient narcotic record, for Lorazepam 0.5 mg (milligram) give half tablet three times a day, read 9 half tablets remained in the blister pack. The blister pack tablet count revealed 8 half tablets remained. - Resident #89's individual patient narcotic record, for Alprazolam 0.25 mg give one tablet three times a day, read 16 tablets remained in the blister pack. The blister pack tablet count revealed 15 tablets remained. At this time, S3LPN confirmed that she gave Resident #71 and Resident #89 their narcotic medications today at 12:23 p.m. and 12:08 p.m., respectively. She stated she did not document in the narcotic book that the medications were given but she should have at the time of administration. She confirmed the narcotic count was inaccurate. On 08/11/2026 at 1:35 p.m., an interview was conducted with S1DON. S1DON confirmed that nurses should document administration of narcotic medications when the medication is administered to prevent an inaccurate narcotic count.

Based on record reviews and interviews, the facility failed to notify the state's Long-Term Care Ombudsman in writing of a discharge for 1 (#123) of 1 (#123) residents reviewed for discharge requirements out of a total sample of 41 residents.Findings:Review of Resident #123's electronic medical record (EMR) revealed an admission date of 06/12/2025, with diagnoses that included cerebral infarction, type 2 diabetes mellitus, and chronic atrial fibrillation. Further review of Resident #123's EMR revealed a discharge summary with a discharge date of 06/23/2025. Continued review of Resident #123's EMR revealed no evidence the State's Long-Term Care Ombudsman had been notified in writing of Resident #123's discharge from the facility on 06/23/2025.On 08/05/2025 at 4:22 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated the Ombudsman had not been notified of the resident's discharge as this is something they do not do.

Based on record review and interview, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the status of 2 (Resident #5 and #55) of 41 sampled residents.Resident #5Review of Resident #5's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to hypertensive heart disease without heart failure, major depressive disorder, shortness of breath, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #5's current physician's orders revealed an order dated 03/08/2025 that read in part, Hydrochlorothiazide (diuretic) oral tablet 25 mg (milligrams) Give 25 by mouth one time a day.Review of Resident #5's MAR (medication administration record) for June 2025 revealed she had been administered Hydrochlorothiazide 25mg for the entire month as ordered.Review of Resident #5's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/19/2025 revealed in Section N (Medications) that she was not coded for diuretic use.On 08/06/2025 at 3:07 p.m., an interview and record review was conducted with S2MDS (Minimum Data Set). She confirmed Resident #5 received Hydrochlorothiazide, which was a diuretic, for the entire month of June 2025 and should have been coded for diuretic use on her annual MDS and was not. Resident #55Review of Resident #55's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified sequelae of cerebral infarction, hypertensive heart disease without heart failure, anxiety disorder, unspecified and dermatitis. Review of Resident #55's nurse's notes dated 01/08/2025 at 10:46 a.m., revealed a stage 2 pressure wound was noted to her sacrum by the treatment nurse. Further review of the nurse's notes dated 01/08/2025 at 3:00 p.m., revealed a DTI (deep tissue injury) was noted to Resident #55's left heel by the treatment nurse.Review of Resident #55's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/30/2025 in Section M (Skin Conditions) revealed she was coded for 2 Stage 3 pressure ulcers that were present upon admission/entry or reentry. On 08/05/2025 at 10:30 a.m., an interview and record review was conducted with S1DON (Director of Nursing). She confirmed the two pressure ulcers identified on 01/08/2025, one to the left heel and one to the sacrum, were both acquired while Resident #55 was in the facility and had been inaccurately coded. On 08/05/2025 at 10:41 a.m., an interview and record review of Resident #55's MDS was conducted with S2MDS (Minimum Data Set). She confirmed Resident #55's MDS had been inaccurately coded for two pressure ulcers as present upon admission and should have been coded as acquired in the facility.

Based on observations, record review, and interviews, the facility failed to implement a person centered care plan by failing to ensure physician orders were followed for heel protectors for 1 (Resident #55) of 41 sampled residents. Review of Resident #55's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified sequelae of cerebral infarction, hypertensive heart disease without heart failure, anxiety disorder, unspecified and dermatitis.Review of Resident #55's current physician's orders revealed an order dated 01/09/2025 that read in part, Apply heel protectors every morning while patient is in bed every day shift.Review of Resident #55's care plan with a focus that read in part, Resident has potential for alteration in skin integrity related to impaired mobility and history of pressure ulcers. Heel protectors when in bed was listed as an intervention for this focus with a date initiated on 05/07/2025.On 08/05/2025 at 09:16 a.m., an observation was made of Resident #55 during wound care in bed with no heel protectors in place.On 08/05/2025 at 10:50 a.m., a second observation was conducted of Resident #55. She was lying in bed with no heel protectors in place.On 08/06/2025 at 9:12 a.m., an interview and observation was conducted with S4ACNA (Agency Certified Nursing Assistant). She stated that she was responsible for caring for Resident #55. Resident #55 was observed lying in bed and not wearing heel protectors. S4CNA stated that she was not sure if Resident #55 should have heel protectors.On 08/06/2025 at 9:51 a.m., an interview, observation, and record review was conducted with S3LPN (Licensed Practical Nurse). S3LPN observed Resident #55 lying in bed and confirmed that she was not wearing any heel protectors. A review of Resident #55's physician's orders and care plan was also conducted with S3LPN and she confirmed that Resident #55 should have had heel protectors on while in bed.

Based on record review and interviews, the facility failed to review and revise the care plan for 1 (#80) of 2 (#9, #80) residents investigated for dialysis out of a sample of 41 residents. Finding: Record review revealed Resident #80 was admitted to the facility on [DATE] with diagnosis not limited to end stage renal disease, hemodialysis, obstructive sleep apnea, type 2 diabetes mellitus, and peripheral vascular disease. Record review of Resident #80 physician orders dated 02/01/2025 read in part, provide foley (urinary catheter) care every shift and change bag and tubing every month. Record output and the end of every shift. Start date of order read 01/02/2025and was discontinued on 02/02/2025. Record review of Resident #80's care plan read in part, C.N.A. (Certified Nursing Asistant) and LPN (Licensed Practical Nurse) monitor intake and output for Resident #80. Start date was listed as 12/31/2024. On 08/06/2025 at 12:30 p.m., S7LPN confirmed during an interview that she does not monitor intake and output on Resident #80. On 08/06/2025 1:30 p.m., S8CNA confirmed during an interview that she does not monitor intake and output on Resident #80. On 08/06/2025 1:45 p.m., S2MDS (Minimum Data Set) Coordinator was interviewed. During the interview, she reviewed Resident #80's physician orders and care plan and confirmed Resident #80's care plan should not include the intervention for LPN and CNA to monitor the resident intake and output. She stated Resident #80's catheter was discontinued on 02/02/2025. On 08/06/2025 at 2:20 p.m., S9QAN (Quality Assurance Nurse) was interviewed. During the interview, she reviewed Resident #80's Care Plan and confirmed the resident's catheter was discontinued and her care plan should not include that the C.N.A. and LPN are to monitor the resident's intake and output.

Based on record review and interview, the facility failed to ensure that nursing services were provided to meet standards of quality as evidenced by failing to ensure nurses conducted a fall risk assessment after each time a resident had a fall, and accurately assessed a resident's fall risk status for 1 (#3) out of 4 (#1, #2, #3, and #4) resident's investigated for falls. Findings: Review of the facility's Fall Assessment and Prevention policy (no date) revealed in part . Purpose: To ensure the safety of the resident residing in the facility. Procedure: 1. Resident will be assessed using the Fall Risk Assessment Form upon admission, re-admission, at the time of the MDS/Care Plan review, and prn (as needed) .4. If a resident has a fall the Fall Assessment Form should be completed. 5. Attempt should be made to determine the cause of the fall document findings. Review of Resident #3's records revealed she was admitted to the facility on [DATE]. Her diagnoses included in part, Age-related Osteoporosis without current Pathological Fracture, Restless Leg Syndrome, History of Falls (02/28/2024), Lack of Coordination, Unsteadiness on Feet, Multiple Fracture of Pelvis with stable disruption of pelvis ring subsequent encounter for fracture, Other specified Disorder of Bone Density and Structure, multiple sites. Review of Resident #3's care plan revealed she had a fall on 05/10/2024, 05/13/2024, and 6/15/2024, 07/28/2024, 08/01/2024, 09/08/2024, 09/13/2024, 09/15/2024, 10/03/2024, and 10/25/2024. Review of the resident's Fall Risk Assessments revealed the facility completed an assessment on 07/03/2024, 08/20/2024 and 10/31/2024, which was at the time of the resident's quarterly Minimum Data Set/Care Plan review. Further review of Resident #3's electronic record revealed there was no fall risk assessment conducted after each of the above falls. Review of the Fall Risk Assessments completed on 07/03/2024 revealed a fall risk score of 9. Under Section A. #2., no falls in past 3 months was selected. On 11/6/2024 at 1:15 p.m., an interview and review of the facility's Fall Assessment and Prevention policy was conducted with S1DON (Director of Nursing). She stated that fall risk assessments were to be completed when a resident was admitted , readmitted and at the time of the Minimum Data Set /Care Plan review. S1DON confirmed a fall risk assessment was not conducted for Resident #3 after each fall. On 11/6/2024 at 1:51 p.m., an interview and review of Resident #3's Fall Risk assessment dated [DATE] was conducted with S1DON. She confirmed that the resident had a fall on 05/10/2024, 05/13/2024 and 6/15/2024, which was prior to the assessment on 07/03/2024. She reviewed the fall risk assessment and stated that Section A . #2 was selected, which indicated that the resident had no falls in the past 3 months prior to the assessment. She stated that the staff should have selected that the resident had 3 or more falls. She confirmed this was an inaccurate assessment of the resident's fall status.

Based on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance with professional standards of practice as evidenced by nurses failing to assess the resident after receiving reports of bruising, swelling, and pain to the resident's right leg for 1 (#4) out of 4 (#1, #2 #3, #4) sampled residents. Findings: Review of Resident #4's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebrovascular Disease, Aphasia, and Displaced Oblique Fracture of Shaft of Right Femur (10/30/2024). Review of the resident's annual MDS (Minimum Data Set) dated 08/06/2024 revealed the resident was coded 3 for being severely impaired for cognition. The resident was coded requiring extensive assistance with 2 plus person assist for bed mobility, and coded requiring total dependence with 2 plus person assist for transfers. Review of the resident's nurse's note dated 10/23/2024 at 9:48 a.m. revealed, Resident c/o (complain of) right hip and leg pain when CNA (Certified Nursing Assistant) changing her under pad and brief this am (morning). (Medical Doctor) notified and ordered Right hip x-ray . Review of the resident's right hip x-ray report dated 10/23/2024 revealed, . Negative for fracture or lytic lesion . There was no x-ray report or order for evaluation of the resident's right leg. Review of the resident's nurse's note dated 10/30/2024 at 8:15 p.m., revealed Late entry---4pm Resident continues to c/o pain to Rt (Right) leg with no effectiveness from pain medicine. Resident also c/o hallucinating and states she feels like she is going to die. Family at bedside and request to go to ER (emergency room ). MD (Medical Doctor) . notified with new order noted to send to ER to eval (evaluate) and tx (treat) . Review of the nurse's note dated 10/30/2024 at 8:23 p.m. revealed, Resident admitted to (hospital) with Rt leg Fracture. On 11/06/2024 at 11:55 a.m., an interview was conducted with S2CNA (Certified Nursing Assistant). S2CNA stated that she worked with the resident the week of 10/21/2024 to 10/25/2024. S2CNA stated that she was assisting another CNA with changing and repositioning the resident in the bed. S2CNA stated that she remembered the resident complaining of pain to the whole right side of her body. S2CNA could not recall the exact date the resident complained of pain. S2CNA stated that she did not know if the resident was complaining of pain to her right arm or right leg because the resident did not communicate verbally and could only gesture that the pain was on the right side from the arm down to her right leg. S2CNA stated the resident's complaint of pain to her right side was reported to the nurse multiple times. On 11/06/2024 at 12:28 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated the resident was nonverbal. S3LPN stated that on 10/23/2024 the CNA reported to her the resident was complaining of pain to her right hip and leg. S3LPN was asked if she asked the resident where the pain was. S3LPN demonstrated on her body how the resident moved her hands from her right hip area down to her right leg was where her pain was. S3LPN stated that she notified the physician and the physician ordered an x-ray of the right hip. S3LPN was asked if she communicated to the physician that the resident's complaint of pain was not related to just the hip, but rather extended down the resident's right leg due to the way the resident demonstrated the location of the pain which would also require an x-ray of the resident's right leg. S3LPN stated she did not ask the physician about getting an x-ray of the right leg because she did not see any swelling to the resident's right leg. On 11/06/2024 at 2:30 p.m., a telephone interview was conducted with S4CNA. S4CNA stated that on 10/23/2024 she assisted S5CNA with changing the resident in bed. S4CNA stated the resident was complaining of pain in her right leg. S4CNA stated that it was reported to the nurse. On 11/06/2024 at 2:40 p.m., an interview was conducted with S5CNA. S5CNA stated the resident was nonverbal. S5CNA stated that on 10/23/2024 she was going to change the resident and the resident was complaining of pain. S5CNA stated the resident pointed to her right side. S5CNA stated that she went to get S4CNA to help her change the resident. S5CNA stated the resident started hollering out in pain while changing her. S5CNA stated the resident complained of pain to the right leg. S5CNA stated the resident's right leg was swollen, and she noticed a bruise to the side of the resident's right leg. S5CNA stated she reported the pain and the bruise to the nurse. S5CNA stated that she worked with the resident again on 10/24/2024. S5CNA stated the swelling to the resident's right leg had increased in size and that the bruise was larger in size from the previous day she worked with the resident. S5CNA stated that she reported the swelling and the bruise to the nurse again on 10/24/2024. Another review of the resident's nurse's notes revealed no evidence the nursing staff assessed the resident's right leg from 10/24/2024 to 10/26/2024 based on the reports of the resident's condition from the CNAs. On 11/06/2024 at 4:46 p.m., an interview and record review was conducted with S1DON (Director of Nursing). S1DON stated that reviewing internal investigations including resident #4's fracture were her responsibility. S1DON confirmed that she reviewed S5CNA's written statement from the investigation conducted regarding the resident's fractured right leg. S1DON confirmed that S5CNA documented she reported that the resident's right leg was swollen and bruised to the nurse on 10/24/2024. S1DON confirmed that there was no evidence the nurse documented an assessment of the resident's right leg in the clinical record from 10/24/2024 to 10/26/2024. S1DON stated that she did not expect her nursing staff to document daily assessments if there were no changes in the resident's status. S1DON stated that she trusted her licensed staff assessments and observations over what the CNAs report to the licensed staff. On 11/06/2024 at 5:15 p.m., an interview was conducted with S6LPN regarding Resident #4's leg for the dates 10/24/2024-10/26/2024. S6LPN stated S5CNA did report the bruising and swelling to the resident's right leg. S6LPN stated that she went in the resident's room to assess the resident's right leg. S6LPN stated the resident did not have any new swelling and that the bruise was an old bruise. S6LPN could not recall the date of the old bruise was first identified. She confirmed that she did not document an assessment of the resident's leg in the resident's clinical record. S6LPN stated that she should have documented the assessment in the resident's clinical record. Review of the resident's medical records and assessments from September 2024 - present revealed no evidence of the resident having a bruise prior to 10/24/2024.

Based on record reviews, observations, and interviews, the facility failed to implement care plan interventions and provide adequate supervision to ensure a cognitively impaired resident, who had a history of wandering did not elope for 1 (Resident #1) out of 3 sampled resident (Resident #1, #2, and #3). This deficient practice resulted in an Immediate Jeopardy on 08/23/2024 at 6:51 p.m. when Resident #1, a severely cognitively impaired resident, was unsupervised and eloped from the facility. On 08/23/2024 beginning at 5:10 p.m., Resident #1 was observed by multiple staff members repeatedly attempting to open several doors throughout the facility before exiting the facility's front entrance door undetected by staff at 6:51 p.m. On 08/23/2024 at 7:03 p.m., the facility received a call from a citizen that observed the resident in a residential area approximately 300 feet away from the facility. Resident #1 was brought back to the facility by staff at 7:10 p.m. Resident #1 was transferred to another facility with a secured unit on 08/28/2024. This deficient practice placed one resident that remained in the facility, who had been assessed as having wandering behaviors, at risk for undetected elopement. S1ADM (Administrator), S2DON (Director of Nursing), and S3ADON (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 09/04/2024 at 2:00 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 5:30 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia with Other Behavioral Disturbance, Bipolar Disorder, Repeated Falls, Unsteadiness on Feet, and Other Lack of Coordination. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 07/17/2024 revealed the BIMS (Brief Interview for Mental Status) of 5, indicating his cognition was severely impaired. Under Section P: Restraints and Alarms revealed the resident had a wander/elopement alarms used daily. Review of Resident Resident #1's current comprehensive plan of care with a target date of 05/21/2024, revealed Resident #1 was an elopement risk/wanderer; initiated on 05/21/2024. Interventions created on 05/21/2024 included in part . Distract resident from wandering . by offering pleasant diversions, structured activities, food, conversation, television, book . Identify pattern of wandering prn: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor locations as needed. Review of Resident #1's physician's orders revealed an order with a start date of 06/24/2024 read in part, Monitor elopement alarm bracelet to right ankle every shift. Review of Resident #1's Elopement Evaluation dated 06/24/2024 revealed in part: Elopement Score: 1.0 (At Risk) BIMS Score: 5 Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? Yes Abnormalities: Verbally expressed desire to go home, packed belongings to go home or stayed near an exit door Clinical Suggestions: Apply personal safety alarm device, Monitor location frequently, and Notify staff of elopement risk. Review of Resident #1's Progress Notes revealed the following: 07/03/2024 at 12:15 p.m., by S4LPN (Licensed Practical Nurse), .Resident trying to open door to leave to go meet his wife . 07/15/2024 at 10:13 a.m., by S4LPN, .Resident away from station pushing on the door. 07/30/2024 at 6:39 a.m., by S4LPN, .Resident ask to open the door so he can go home multiple times. Explained to resident multiple times I cannot open the door and he lives here now. Resident says no and pushes on the door. Unable to redirect resident . Review Resident #1's Incident Report completed on 08/23/2024 at 9:23 p.m. by S5LPN, read in part . 7:02 pm received a call from neighbors across the street from the facility stating that resident was down .street. This nurse as well as all staff members around when the call came in rushed outside the facility. Resident was down (street) near the house before the intersection . were able to get the resident back into the facility, elopement alarm bracelet present on resident . Predisposing Situation Factors: active exit seeker and wanderer were checked . Review of Witness Statement completed on 08/23/2024 by S6LPN, revealed the following . Last time I seen Resident #1 he was wandering the hallways of Hall W going to Hall W's west side back door trying to open it, when it didn't open he turned around and went another direction. Review of Witness Statement completed on 08/23/2024 by S6LPN, revealed the following . Last time I saw resident was at the door by the nurse's station trying to get out. Then when another resident told him the doors were locked; he went down the hall toward the dining room. Review of Witness Statement completed on 08/23/2024 by S7Laun (Laundry Staff), read in part .Last time was when the medicine man was here Resident #1 was at the back door, I told the man to hide on the side of the breakroom until Resident #1 passes then Resident #1 left . Review of the facility's video surveillance on 09/03/024 at 1:15 p.m. with S2DON, revealed on 08/23/2024 at 5:10 p.m., Resident #1 was sitting in his wheelchair pushing on the exit door in the dining room. On 08/23/2024 between 5:13 p.m. - 6:32 p.m. Resident #1 was observed pushing on three different exit doors on Hall W. He was observed pushing on each door more than once every few minutes. Multiple staff members were visible in the facility's video surveillance who observed Resident #1 push on different exit doors on the Hall W. No staff members on video surveillance approached the resident to redirect or distract the resident from pushing on the doors. On 08/23/2024 at 6:36 p.m., Resident #1 was seen pushing on the back entrance door. Between 6:37 p.m. - 6:46 p.m. Resident #1 was observed going back and forth between the front lobby entrance door and back entrance door every few minutes. At 6:48 p.m. Resident #1 was seen on video surveillance pushing on the back entrance door. During this time, S7Laun came out of the laundry room and watched the resident push on the back entrance door. On the video surveillance, S7Laun had not approached the resident and was seen going back into the laundry room. At 6:51:05 p.m., Resident #1 was seen at the front lobby door attempting to push on the door with his hands and ramming his wheelchair into the door. At 6:51:23, the front lobby door opened and Resident #1 eloped from the facility. On the facility's video surveillance, no staff was observed near the front lobby door during any of the times Resident #1 was seen pushing on the door. On 09/03/2024 at 11:00 a.m., an interview was conducted with S6LPN. S6LPN stated she worked on the Hall W the evening Resident #1 eloped from the facility. She stated she observed him at approximately 6:15 p.m. trying to push open the exit doors several times on the Hall W and wander around the facility. She confirmed she never attempted to intervene by redirecting or distracting the resident when he was pushing on the exit doors and had not notified S5LPN, his assigned nurse, of the exit seeking behaviors Resident #1 had displayed. She confirmed she had not any heard alarm the evening of 08/23/2024 when Resident #1 eloped from the facility. Multiple attempts were made to contact S5LPN via phone on 09/03/2024 at 11:17 a.m., at 11:48 a.m., 12:25 p.m. and at 2:14 p.m. S5LPN failed to return any phone calls and was unable to be interviewed. On 09/04/2024 at 2:29 p.m., an interview was conducted with S7Laun. She stated on the evening of 08/23/2024 she worked in the laundry room which was on the same hall as the back entrance door. She confirmed that she had observed Resident #1 at the back entrance door trying to push it open and had not approached the resident to try to redirect him and had not notified his nurse. On 09/03/2024 at 3:17 p.m., an elopement alarm bracelet was tested at the front lobby door with S2DON. The alarm activated when the elopement alarm bracelet was approximately 10 feet away from the front lobby door and upon demonstration the front lobby door alarm's volume was very faint. On 09/03/2024 at 4:10 p.m., an interview was conducted with S2DON. S2DON stated that in June 2024 an elopement alarm bracelet was applied on the resident due to exit seeking behavior such as Resident #1 telling multiple staff members that he wanted to go home. She stated that in July 2024 he had multiple exit seeking behaviors by pushing on the exit doors several times throughout the day. She stated on 08/23/2024, when the resident was displaying exit seeking behaviors on the Hall W, the staff could have redirected him. However, he would have went back to repeating the same behavior because that was normal for him. She stated the facility relied on all the elopement alarm and locking mechanism located on the front lobby door and back entrance door that activated when a resident with an elopement alarm bracelet was nearby. She stated there was no explanation or reasoning of why Resident #1 eloped from the facility other than the front lobby door possibly glitched when Resident #1 pushed on the door and pushed his wheelchair in the door which caused it to open. On 09/04/2024 beginning at 8:33 a.m., the elopement alarm bracelet volume was tested near the front lobby door: 1. On 09/04/2024 at 8:33 a.m., an interview was conducted with S6LPN on Hall W's nurse's station approximately 100 feet away from the front lobby door. The front lobby door alarm was activated. S6LPN confirmed that she could not hear the alarm. 2. On 09/04/2024 at 8:35 a.m. the front lobby door alarm was activated. Observation made of S2DON sitting in her office with the office door open. Her office was located approximately 90 feet away from the front lobby door. S2DON did not respond to the elopement alarm bracelet. 3. On 09/04/2024 at 8:38 a.m., an interview was conducted with S8CNACoor (Certified Nursing Assistant Coordinator) on Hall X's nurse's station located approximately 111 feet away from the front lobby door. The front lobby door alarm was activated. S8CNACoor confirmed that she could not hear the alarm. 4. On 09/04/2024 at 9:31 a.m., an interview was conducted with S1ADM near an exit door on Hall W located approximately 130 feet away from the front lobby door. The front lobby door alarm was activated. S1ADM confirmed that he could not hear the alarm. 5. On 09/04/2024 at 9:35 p.m. the front lobby door alarm was activated. The farthest the alarm could be heard was approximately 53 feet away near the beauty salon. On 09/04/2024 at 10:52 a.m., an interview was conducted with S9LaunSup (Laundry Supervisor). She stated the laundry room was on the same hall as the back entrance door and if a resident with an elopement alarm bracelet goes near the door the alarm activated and she expected laundry staff to check on the alarm and respond. She stated if the alarm was activated due to a resident with an elopement alarm bracelet being near the back door then laundry staff should have checked on the resident, persuaded them to turn around away from the door, and bring the resident to their nurse and notify them of what their resident was doing. On 09/04/2024 at 4:33 p.m., an interview was conducted with S1ADM. S1Admin stated Resident #1 was readmitted back to the facility in May 2024 and throughout his stay he could tell that the resident did not want to be here. The resident always walked around the facility and showed exit seeking behavior such as telling the staff he wanted to go home to his wife. An elopement alarm bracelet was applied after the resident displayed these behaviors. S1ADM stated he had observed Resident #1 pushing on exit doors numerous times. S1ADM confirmed that nursing staff should have attempted to redirect Resident #1 when they saw him pushing on the exit doors down the Hall W several times on 08/23/2024. He confirmed when laundry staff observed Resident #1 pushing on the back entrance door she should have intervened and got that resident's LPN. He stated staff relied on the elopement alarm bracelet lock mechanism on doors to prevent elopement. He confirmed Resident #1 left the building and the facility's premises undetected by staff. He confirmed the front lobby door was not monitored by staff to prevent Resident #1's elopement.

Based on observations, interviews and record reviews, the facility failed to ensure resident's remained free from accidents for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) investigated for falls. The facility failed to ensure: 1. night staff got resident out of bed during last rounds, and 2. the resident's wheel chair alarm was properly working. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Repeated Falls, Cognitive Communication Deficit, and Unsteadiness on Feet. Review of Resident #1's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/29/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 05, indicating he had severe cognitive impairment. Section GG Functional Abilities and Goals revealed he used a walker and required supervision for toilet transfer, sit to stand, chair/bed-to-chair transfer and walking 10 feet. Further review of Resident #1's MDS revealed he had a history of falls in the last 2 - 6 months. Review of Resident #1's care plan revealed the following focus areas and interventions: Increased risk for falls (initiated 05/21/2024) related to diagnosis of dementia, confusion, psychoactive drug use, unaware of safety needs, wandering and unsteady gait. Interventions included but not limited to, be sure the resident's call light is within reach (dated 05/21/2024 and revised on 06/24/2024) and encourage the resident to use it for assistance as needed (dated 05/21/2024 and revised on 06/24/2024). He was also care planned for having actual falls initiated on 06/24/2024 with revision on 07/09/2024. Interventions for the actual falls included in part, staff to redirect as needed (initiated 06/24/2024 with revision on 06/27/2024); staff to remind resident to allow them to assist with needs and encourage resident to call for assistance initiated 06/24/2024 with revision on 06/27/2024); Further review of Resident #1's care plan revealed special instructions on only the first page of the 43 page care plan that included: Wanderguard (elopement prevention bracelet), Bed mobility=Supervision, Transfers=Supervision, Toileting=Supervision, Eating=Supervision, Bed/Chair Alarm, Fall Mats x 2 (times two), and night shift to get resident up around 05:00 a.m. There were no dates next to the items listed in the special instructions. Per facility incident report reviews, night shift to get resident up around 05:00 a.m. was on initiated 07/01/2024. Resident #1's facility incident investigation reports revealed the following: 07/01/2024 at 7:00 a.m., Unwitnessed Fall. Resident found on floor in his room with bed alarm sounding. Resident confused per usual. No injuries observed post incident. Post fall interventions: Continue Physical Therapy and Physical Therapy evaluation, increase supervision due to frequent falls, night shift advised to get resident out of bed on 5:00 a.m. rounds if he is awake. 07/04/2024 at 05:05 a.m., Unwitnessed Fall. Resident found sitting on floor on floor mat next to bed with no injuries. Bed alarm was sounding. Confused per his usual. Post fall interventions: Physical Therapy evaluation and provided urinal at bedside. 07/06/2024 at 06:00 a.m., Unwitnessed Fall. Resident found lying on floor on floor mat beside bed. Bed alarm activated. Confused per his usual. No injuries observed post incident. Post fall interventions: Physical Therapy evaluation, collect Urine Analysis, in-service night shift that resident needs to be assisted out of bed and into wheelchair on last rounds. 07/06/2024 at 03:56 p.m., Witnessed fall. Resident fell trying to go from wheelchair to regular chair in lounge room. Confused per his usual. There were no new injuries. Post fall interventions: Physical Therapy evaluation and staff in-serviced to assist resident with all transfers due to increased weakness. Review of an in-service dated 07/01/2024 (with no time listed) revealed the summary of subject was to provide increased supervision and assist with all transfers for Resident #1 due to increased pain and weakness. The summary of subject for the in-service did not include to get the resident out of bed on 5:00 am rounds which was listed as an intervention in response to the fall he had on 07/01/2024 at 7:00 a.m. Review of an in-service dated 07/08/2024 revealed the summary of subject was that the night shift needed to get Resident #1 up into wheelchair during last rounds. The in-service occurred after the resident sustained 3 falls in his room on 07/01/2024, 7/4/2024, and on 7/06/2024 between the hours of 5:05 a.m. and 7:00 a.m. (night shift). On 07/10/2024 at 10:39 a.m., a phone interview was conducted with S6ACNA (Agency Certified Nursing Assistant) whom was working the morning of 07/04/2024 at 5:05 a.m. when Resident #1 had an unwitnessed fall in his room. She stated that Resident #1 was trying to go to the bathroom. She stated that she was not aware that Resident #1 was supposed to be gotten up on her last rounds of the night shift. S6ACNA stated that it had not been reported to her. On 07/10/2024 at 1:28 p.m., surveyor observed Resident #1 in his room lying face down on the floor next to his roommate's bed. His wheelchair was at the foot of the roommate's bed with his chair alarm attached. There was no audible sound coming from the alarm. Resident #1 was saying Help me up. Surveyor then pressed the resident's call light to summon help. S3LPN and S4LPN reported to the resident's room to assist the resident. S3LPN confirmed that the resident's alarm was not functioning and removed the resident's chair alarm. On 07/10/2024 at 2:31 p.m., an interview was conducted with S3LPN. She confirmed that Resident #1's wheelchair alarm did not produce a sound when he fell out of his wheelchair. She stated when she opened the alarm, there were no batteries in the chair alarm for it to sound. On 07/10/2024 at 2:55 p.m., a phone interview was conducted with S4LPN. She confirmed that Resident #1's chair alarm was not working when he fell . On 07/10/2024 at 4:16 p.m., an interview was conducted with S2ADON. A review was conducted of all incident investigations regarding Resident #1's falls. She stated an in-service had been conducted on 07/08/2024 for night shift getting Resident #1 up into his wheelchair on their last rounds because she did not believe that they were getting the resident up due to having two more falls in the early morning hours. She confirmed that Resident #1 had fell today and that his wheelchair alarm did not have any batteries.

Based on observations and interview, the facility failed to maintain and clean, comfortable, and homelike environment by failing to ensure clean bed linen was provided to 1 (#46) out of 2 (#24 and #46) residents investigated for homelike environment. Findings: On 06/26/2024, a review of the facility's policy titled Bed Making - Unoccupied Bed with a last reviewed date of 04/29/2024 read in part . Purpose: To provide a clean and comfortable bed for the residents . Essential Points . Change any soiled or dirty linen . Review of Resident #46's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Muscle Wasting and Atrophy, Lack of Coordination, and Spondylosis without Myelopathy. On 06/24/2024 at 12:15 p.m. an observation was made of Resident #46's room. Resident #46 was sitting in his wheelchair. The bed was observed not made and the resident's pillow case revealed a medium size yellow stain, and multiple areas of small light brown stains on the resident's bed linen. On 06/24/2024 at 2:19 p.m. a second observation was made of Resident #46's bed. The bed was observed and was made. The resident's pillow case revealed a medium size yellow stain, and multiple areas of small light brown stains on the resident's bed linen. On 06/24/2024 at 2:22 p.m. an interview and observation of Resident #46's room was conducted with S3LPN (Licensed Practical Nurse). She confirmed that Resident #46's bed was made. S3LPN confirmed the stains on pillow case and bed linens and she confirmed there should not be any stains on linen and it should have been changed before the bed was made. On 06/26/2024 at 2:24 p.m. an interview was conducted with S1DON (Director of Nursing). S1DON confirmed bed linens should be clean at all times and if stains are noted on linens they should be changed.

Based on observations, interviews, and record review, the facility failed to follow a physician's order and care plan for 1 (#95) of 40 sampled residents by failing to ensure the resident's TED (Thrombo-Embolic Deterrent) hoses were applied as ordered. Findings: Resident #95 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Chronic Obstructive Pulmonary Disease, Essential Primary Hypertension, and Unspecified Atrial Fibrillation. A review of quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/26/2024, revealed Resident #95 had a BIMS (Brief Interview of Mental Status) score of 15, indicating her cognition was intact. A review of Resident #95's physician orders revealed an order written on 03/01/2024 to apply TED hose in the AM (morning) and remove at night. A review of Resident #95's June 2024 care plan revealed she had Hypertension r/t (related to) dx (diagnosis) of Essential Primary Hypertension and Atrial Fibrillation with a goal to remain free of complications related to Hypertension. Interventions in part .Compression stockings on in the AM, off in PM (afternoon). On 06/24/2024 at 12:23 p.m., an observation was made of Resident #95 in her room. The resident was sitting in her reclining chair. Further observation revealed she was wearing black slippers with no TED hoses on. On 06/25/2024 at 9:04 a.m., an observation and interview was conducted with Resident #95. She was sitting in her chair and no TED hoses were on her legs. When asked, Resident #95 stated that the nurse did not offer to put her TED hose on yesterday (06/24/2024) or today (06/25/2024). On 06/25/2024 at 9:09 a.m., an observation and interview of Resident #95 was conducted with S4LPN (Licensed Practical Nurse). She confirmed that the resident was not wearing her TED hoses and stated that she did not put them on the resident yesterday (06/24/2024) or today (06/25/2024).

Based on observation, interview, and record review, the facility failed to ensure oxygen equipment was stored appropriately when not in use for 1 (Resident #97) out of 2 (Resident #83, Resident #97) sampled residents reviewed for respiratory care. Findings: Review of Resident #97's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery, and COVID-19. Review of Resident #97's June 2024 physician's orders revealed an order dated 04/08/2024 for O2 (oxygen) at 2L/MIN/NC (liters per minute per Nasal Cannula) PRN (as needed) to relieve hypoxia. Review of Resident #97's care plan read in part .Resident has oxygen therapy as needed for SOB (shortness of breath). Interventions included: Oxygen Settings: 02 at 2L per nasal cannula as needed. On 06/24/2024 at 12:04 p.m., an observation was made of Resident #97's room. An oxygen concentrator was observed near the resident's wall while not in use. The nasal cannula tubing was draped over the oxygen concentrator open to air, with the nose piece of the tubing making contact with the machine. On 06/24/2024 at 12:11 p.m., S3LPN (Licensed Practical Nurse) was asked to enter Resident #97's room. S3LPN observed the oxygen concentrator machine and confirmed the nasal cannula tubing was open to air and not stored appropriately. S3LPN stated the nursing staff was responsible for storing nasal cannula tubing in a bag when not in use.

Based on observations, interviews and record reviews, the facility failed to ensure the nursing staff demonstrated specific competencies and skill sets necessary to provide care to meet the residents' needs safely to attain or maintain the highest practicable physical well-being for 1 (#95) of 40 sampled residents. This was evidenced by S4LPN (Licensed Practical Nurse) leaving Resident #95's medication at the bedside. Findings: On 06/25/2024, a review of the facility's policy titled Medication Administration - Oral with a revision date of 04/29/2024 read in part, It is the policy of the _____ to administer medications in a safe manner .The person administering medication must remain with the resident until all medication has been swallowed. Resident #95 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Chronic Obstructive Pulmonary Disease, Essential Primary Hypertension, and Unspecified Atrial Fibrillation. A review of Resident #95's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/26/2024, a BIMS (Brief Interview of Mental Status) score of 15 indicating her cognition was intact, but the resident had no documents in her medical records that she was able to self administer her medications. A review of Resident #95's physician orders revealed the following orders: -1/19/2024 Pantropazole Sodium Oral Tablet Delayed Release 40 mg (milligram) give 1 tablet by mouth 2 times a day -1/19/2024 Venlafaxine HCL (Hydrochloride) Oral Tablet 25 mg give 1 tablet by mouth three times a day. -1/20/2024 Allopurinol Oral tablet 100 mg give 1 tablet by mouth one time a day. -1/20/2024 Amiodarone HCL oral tablet 200 mg give 1 tablet by mouth one time a day. -1/20/2024 Icar-C Oral Tablet 100-250 mg give 1 tablet by mouth one time day. -1/20/2024 Levothyroxine Sodium Oral Tablet 75 MCG (Microgram) give 1 tablet by mouth one time a day. -1/20/2024 Metoprolol Succinate ER Oral Tablet Extended release 24 hour 25 mg give 0.5 tablet by mouth one time a day. -1/20/2024 Multivitamin Oral Tablet give 1 tablet by mouth one time a day. -1/21/2024 Prednisone oral tablet 5 mg give 1 tablet by mouth one time a day every other day. -6/08/2024 Folic Acid Oral Tablet Give 1 mg by mouth one time a day related to anemia -6/10/2024 by Lasix Oral Tablet 20 mg (Furosemide) Give 20 mg by mouth one time a day. A review of Resident #95's Medication Audit Report revealed the following medications were administered by S4LPN (Licensed Practical Nurse) on 06/25/2024 at 6:29 a.m.: -Levothyroxine Sodium Oral Tablet 75 MCG. Give 1 tablet by mouth one time a day. -Metoprolol Succinate ER Oral Tablet Extended Release 24 hour 25 MG. Give 0.5 tablet by mouth one time a day. -Allopurinol Oral Tablet 100 MG Give one tablet by mouth one time a day. -Pantoprazole Sodium Oral Tablet Delayed Release 40 mg. Give 1 tablet by mouth two times a day. -Icar-C Oral Tablet 100-250 MG Give 1 tablet by mouth one time a day. -Multivitamin Oral tablet. Give 1 tablet by mouth one time a day. -Venlafaxine HCL Oral tablet 25 MG Give 1 tablet by mouth 3 times a day. -Folic Acid Oral Tablet. Give 1 MG by mouth one time a day. -Lasix Oral Tablet 20 mg. Give 20 MG by mouth one time a day. -Amiodarone HCL Oral Tablet 200 MG. Give one tablet by mouth one time a day. -Prednisone Oral Tablet 5 MG. Give 1 tablet by mouth one time a day every other day. On 06/25/2024 at 9:04 a.m., an observation was conducted of Resident #95 in her room. A clear plastic medicine cup containing 11 pills was observed on the resident's over bed table. On 06/25/2024 at 9:09 a.m., an observation was made of Resident #95's room with S4LPN (Licensed Practical Nurse) followed by an interview. She confirmed that she left the medications in the clear plastic cup at the resident's bedside. On 06/25/2024 9:45 a.m., an interview was conducted with S1DON (Director of Nursing). She stated according to the facility's policy that nurses are not supposed to leave medications at residents' bedside.

Based on observations and interview, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. Two opened packages of hamburger buns not labeled with the date. 2. Food storage: A. Cooler: 1. One opened Liquid Protein container not labeled with the date. 2. One opened Chocolate Desert Topping not labeled with the date and an expiration date of [DATE]. B. Walk-in freezer: 1. One opened bag of garlic bread not labeled with the date. 2. One opened bag of sweet potato fries not labeled with the date. The total amount of residents that ate out of the kitchen was 112 residents. Findings: On [DATE] at 9:50 a.m., an initial tour of the facility's kitchen was conducted with S5DC (Dietary Cook). S5DC confirmed the two opened packages of hamburger buns were not labeled with the date. On [DATE] at 9:57 a.m., an interview and observation was conducted with S2DM (Dietary Manager). S2DM confirmed the above findings were opened and not labeled and should have been. She also stated the expired item should not be in the cooler.

Based on interviews and record review, the facility failed to maintain accurately documented medical record in accordance with accepted professional standards and practices. The facility failed to accurately document on the TAR (Treatment Administration Record) for 1 (#98) out of 1(#98) sampled resident reviewed for urinary catheter or UTI (Urinary tract infection) in a final sample of 40 residents. Findings: Review of Resident #98's April 2024 Treatment Administration Record (TAR) revealed the nursing staff failed to initial suprapubic catheter site care and treatment on the resident's left toe and malleolus were performed on the following dates: 04/07/2024, 04/09-04/10-2024, 04/12/2024, 04/15-04/16/2024 and 04/21/2024. Review of Resident #98's May 2024 Treatment Administration Record (TAR) revealed the nursing staff failed to initial that treatment on the resident's left toe were performed on the following dates: 05/01/2024, 05/04-05/05/2024, 05/11-05/12/2024. Further review of the May 2024 TAR revealed the nursing staff failed to initial that suprapubic catheter care was performed every shift on the following dates: Day shift: 05/04-05/05/2024, 05/11-05/12/2024, 05/18-05/19/2024, and 05/25-05/26/2024; Evening shift: 05/06-05/07/2024, 05/11-05/14/24, 05/20-05/21/2024, and 05/25-05/28/2024; Night shift: 05/01/2024, 05/07/2024, 05/11-05/12/2024, and 05/25/2024. Review of Resident #98's June 2024 Treatment Administration Record (TAR) revealed the nursing staff failed to initial that suprapubic catheter care was performed every shift on the following dates: Day shift: 06/01-06/02/2024, 06/07-06/08/2024, and 06/21-06/22/2024; Evening shift: 06/01-06/04/2024, 06/07/2024, 06/09-06/11/2024, 06/15/2024, 06/17-06/18/2024, and 06/23-06/24/2024; Night shift: 06/06/2024, 06/20-06/21/2024, and 06/24-06/25/2024. On 06/27/2024 at 2:09 p.m., an interview and review of the resident's April, May and June 2024 TARs was conducted with S1DON (Director of Nursing). She confirmed there were multiple days on the April, May and June 2024 TARs that were not initialed by the nursing staff. She stated that the treatment nurse and/or the nurse should initial the TAR when they conduct a treatment.

Based on interview and record review the facility failed to ensure that a resident's person-centered plan of care was implemented for monitoring adverse reactions of Plavix and Aspirin for 1 (Resident #2) out of 3 (Resident #1, #2, and #3) sampled residents. Findings: Review of Resident #2's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Occlusion and Stenosis of Unspecified Carotid Artery, Heart Failure, and Chronic Pulmonary Edema. Review of Resident #2's Quarterly MDS (Minimum Data Set) dated 04/17/2024 revealed the Brief Interview for Mental Status (BIMS) of 8, indicating her cognition was moderately impaired. Under Section N: Medications revealed the resident received antiplatelets. Review of Resident #2's physician's orders revealed an order entry with a start date of 05/01/2020 read in part, Aspirin EC (enteric coated) tablet delated release 81 mg (milligram) give 1 tablet by mouth one time a day related to Occlusion and Stenosis of Unspecified Carotid Artery. Further review of Resident #2's physician's orders, revealed an order with a started date of 05/01/2020 of Plavix Tablet 75 mg (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day related to Occlusion and Stenosis of Unspecified Carotid Artery. Review of Resident #2's person-centered plan of care, revealed in part, a focus of Resident #2 is on Plavix and Aspirin r/t (related to) occlusion and stenosis of carotid artery with an intervention to monitor/document/report PRN (as needed) adverse reactions of therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changed in mental status, significant or sudden changes in v/s (vital signs). Review of Resident #2's MAR (Medication Administration Record) and TAR (Treatment Administration Record) from March, April, and May 2024 did not reveal documentation of monitoring for adverse reactions of Aspirin or Plavix as ordered on the person-centered plan of care. On 05/28/2024 at 3:10 p.m., an interview was conducted with S1DON (Director of Nursing) who confirmed that Resident #2 was taking Aspirin 81 mg and Plavix 75 mg as ordered. S1DON reviewed Resident #2's person-centered plan of care and confirmed the order of monitoring and documented adverse reactions of Plavix and Aspirin. S1DON also reviewed Resident #2's MAR and TAR from March, April, and May 2024 and confirmed there was no monitoring of adverse reactions of Aspirin and Plavix that was done by nursing staff. S1DON confirmed that monitoring of adverse reaction of Aspirin and Plavix should have been done and documented on the MAR/TAR every shift as ordered on the person-centered plan of care and was not.

Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a chair to bed transfer for 1 (#1) of 4 (#1, #2, #3, and #R1) sampled residents. This deficient practice resulted in actual harm for Resident #1 on 03/25/2024 at 5:37 p.m. when S5CNA (Certified Nursing Assistant) transferred the resident from chair to bed without assistance of another person and without the use of a mechanical lifter as required by his plan of care. On 03/26/2024 at 10:30 a.m., S3ADONWC observed Resident #1's right lower leg as discolored and painful upon movement. X-ray of the resident's right lower leg, dated 03/26/2024, revealed a tibia (shin bone) fracture. On 03/29/2024 at 11:26 a.m., S9MD (Medical Doctor) observed swelling and discoloration to the resident's left lower leg and ordered an x-ray. X-ray of the resident's left lower leg, dated 03/29/2024, revealed a fracture of the distal tibial metaphysis (lower part of the shin bone). Resident #1 was on hospice services and received treatment for the fractures in the facility. The facility implemented a corrective action plan on 03/26/2024 which was prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the medical records for Resident #1 revealed he was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Age-related Osteoporosis, Pain, and Paranoid Schizophrenia. The resident was on hospice care. Review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/12/2024, revealed the following, in part: BIMS (Brief Interview for Mental Status) of 11, which indicated the resident, had moderate cognitive impairment. Bed mobility - dependent (staff does all the effort); Sit to stand - Not attempted due to medical condition or safety concerns; Chair/bed to chair transfer (ability to transfer to and from a bed to a chair or wheelchair) - dependent. Review of Resident #1's current care plan revealed the following, in part: The resident has an ADL (activity of Daily Living) self-care performance deficit r/t (related to) End stage Parkinson's disease, impaired mobility .Osteoporosis, Osteogenesis Imperfecta. Interventions: The resident requires total assistance by two staff with the use of a mechanical lifter to move between surfaces. Review of Resident #1's nursing notes revealed the following, in part: 03/26/2024 at 10:38 a.m., S6LPN (Licensed Practical Nurse) was called to the resident's room by S3ADONWC (Assistant Director of Nursing/Wound Care Nurse). S3ADONWC stated that while performing the resident's treatments she discovered discoloration to his right lower extremity (RLE) and the resident complained of pain when moved. The resident was unable to say what happened. She notified the hospice RN (Registered nurse). Vital signs: Bp (Blood pressure)-115/58, P (Pulse) - 93, R (Respirations) - 18, T (Temperature) - 98.3. Further review revealed the resident's doctor ordered X-ray of RLE at 11:00 a.m. 04/01/2024, a late entry by S2DON (Director of Nursing) for 03/26/2024 at 2:19 p.m., revealed that she received the X-ray results of fracture to the right tibia. She notified the resident's doctor and responsible party. 03/29/2024 at 11:26 a.m., S6LPN wrote that the resident's doctor placed a splint to the RLE and ordered an X-ray for his left foot and ankle d/t (due to) swelling and discoloration . 03/29/2024 at 4:40 p.m., S2DON wrote that she received a call from the x-ray facility stating that the resident had a fracture to his left ankle. She notified the resident's doctor and responsible party. Review of Resident #1's x-ray results revealed: 03/26/2024 - X-ray of right knee, tibia and fibula revealed a non-displaced acute fracture of the proximal tibia. 03/29/2024 - X-ray of left ankle and foot revealed an acute mildly displaced fracture, distal tibial metaphysis. Review of the facility's investigative report revealed the following, in part: On 03/26/2024 at 10:19 a.m., S3ADONWC called S6LPN to Resident #1's room. S3ADONWC informed S6LPN that while she was performing the resident's treatments, she observed discoloration to his RLE and the resident complained of pain when she moved him. The resident was unable to state what happened. Video surveillance by the facility on 3/25/2024 revealed that S5CNA entered the resident's room to put him to bed at 5:37 p.m., alone and without a lifter. When questioned she S5CNA stated that she transferred the resident using a pivot method, placing one leg in between the resident's legs and lifting him up under his arms and pivoting him into his bed. She stated the resident did not complain of pain until her last round at 9:00 p.m. Based on witness statements, review of training records and a signed probation form, S5CNA understood the procedures involved for properly transferring the resident. The facility suspended S5CNA during the investigation, performed employee counseling and re-training, and she was placed on 90 days probation. S5CNA failed to secure a second person and a lifter to transfer the resident. A finding of neglect is substantiated, as this aide failed to follow the resident's care plan. On 04/09/2024 at 8:16 a.m., an observation was made of Resident #1 with S3ADONWC of the resident in his room. S3ADONWC removed the resident's covers and revealed a clean soft splint to his right leg with ace wrap up to his knee. The resident has a knee high black boot splint to his left leg. The resident stated he was experiencing no pain when asked. On 04/09/2024 at 8:08 a.m., an interview was conducted with S3ADONWC who stated that she discovered the resident's first injury on 3/26/2024. S3ADONWC stated that on 3/25/2024, S4CNA and the shower aide showered the resident and used the lifter to put him back in bed. She stated she changed the resident's dressing and did not notice any bruising or swelling in his legs, and the resident did not complain of pain. S3ADONWC stated that the next day she went into the resident's room for wound care and assessment. When she pulled back the resident's covers, she noticed his right lower leg was swollen and bruised and the resident complained of pain. S3ADONWC stated she asked the resident what happened and he said, That girl hurt my leg. S3ADONWC stated that she called S6LPN to see if she knew anything and she said she did not. S3ADONWC stated she finished the resident's dressing change while S6LPN called the hospice nurse and doctor to report the findings. S3ADONWC stated his doctor ordered an x-ray which revealed a fracture. On 04/09/2024 at 8:25 a.m., an interview was conducted with S4CNA who stated that she has been working at the facility for about two years and is familiar with the resident. She stated that the resident is transferred with two people and a lifter. S4CNA stated that on 03/25/2024, she got the resident up for his shower with the lifter and assistance from the shower aide. She stated they got him back in bed then went to get S3ADONWC to do his skin assessment and dressing. S4CNA stated that the resident had no bruising or swelling on his legs and did not complain of any pain. She stated that the next day S2DON and S6LPN asked her if she had noticed any bruising, swelling, on the resident's legs when she cared for him the previous day and she told them she had not. On 04/09/2024 at 10:05 a.m., an interview was conducted with S2DON. She stated that she started the investigation into the incident immediately after it was discovered on 03/26/2024. She stated that video surveillance identified S5CNA going into the resident's room on 03/25/2024 at 5:37 p.m., with the resident in his Geri-chair. She stated S5CNA was alone and did not come out to get help or a lifter. S2DON stated S5CNA confessed to transferring the resident by herself without a lifter and assistance from other staff, and was suspended during investigations. She stated that after three days suspension she was counseled and is currently on 90 days of probation that ends in July 2024. S2DON further stated that S1AsstADM (Assistant Administrator) started a QAPI (Quality Assessment and Improvement) project. On 04/09/2024 at 10:13 a.m., an interview and review of the facility's plan of correction was conducted with S1AsstADM. S1AssitADM stated that after S2DON investigated the incident, they agreed there was a problem, and a QAPI was started on 03/26/2024. She stated that in-services began on 03/26/2024 and monitoring began the following day. S1AsstADM was asked when the plan of correction will be completed and she stated that on the last week of monitoring the committee will determine if compliance was achieved and whether they need to end or extend the monitoring. On 04/16/24 at 09:10 a.m., a phone interview was conducted with S5CNA. She did not normally work on Resident #1's hall and in the past he was always in bed when she saw him. She was not used to seeing him in a chair. When she put him back in the bed on 03/25/2024, she did so by herself using a pivot method. She stated that she should have looked in his care plan before she transferred him. She stated when she returned to work she was in-serviced on 2 person transfers using a lift and on checking the chart for direction on what type of transfer assistance the resident required before providing caring to any resident. During the training, a demonstration was provided and she performed a return demonstration on lift transfers and checking the care plan. She stated that S2DON and S10CNASup randomly monitor transfers and they are usually the ones that watched her when she was transferring residents. On 04/16/2024 at 9:45 a.m., during an interview with S2DON, she stated that S5CNA's first day back at work was 04/06/24. She was in-serviced prior to providing care to residents and continues to be monitored for transfers and for using the care plan to determine how residents are to be transferred. She stated that S5CNA told her there was no lifter pad under the resident when she went to transfer but that when they reviewed the video footage, they could clearly see the big blue lifter pad under the resident as she brought him into the resident's room.``` Multiple staff members were interviewed regarding transfer of residents and how to find the instructions for each resident they care for. All staff members stated they were trained on hire and had yearly competency checks on using mechanical lifts. They were also knowledgeable on where to find care instructions in the kiosk for each resident. Observations were made on 04/08/2024 and 04/09/2024 of nursing staff transferring residents using mechanical lifts. No concerns noted. The facility has implemented the following actions to correct the deficient practice: 03/26/2024- Clinical/Administrative Corrective Action Plan: 1. S5CNA, who improperly transferred resident, was suspended immediately. 2. Employee Counseling on 03/28/2024 and signing of probation after suspension on 04/06/2024. 3. Staff in-serviced to follow care plan on 03/26/2024 4. Building wide in-service on following the care plan and looking at special instructions in grey area of chart on 03/26/2024. 5. Proper Transfer Use Monitoring Tool started on 03/27/2024. This will be checked 5 times each week for 2 weeks, 2 times each week for 2 weeks and 1 time a week for 1 week by administration staff. 6. Review of the monitoring 03/27/2024 through 04/11/2024 revealed it was being conducted as care planned. No issues with transfers noted. Review of a separate monitoring sheet revealed S5CNA was monitored to ensure residents were transferred according to their care plan on 04/06/2024, 04/08/2024, 04/10/2024, and 04/14/2024. Monitoring was conducted by S2DON and S10CNASup. 32512

Based on record reviews, interviews and observations, the facility failed to ensure the residents call system was functioning properly for 2 (Hall B and Hall C) of 3 halls (Hall A, Hall B and Hall C). The deficient practice was evidenced when: 1. Resident #2's RP (responsible party) filed a grievance regarding Resident #2 pressing her call bell, and staff failing to assist the resident because the call system was not functioning properly and 2. A bed alarm was tested on site in Room A and immediately after bed alarm was deactivated, the resident call system for 2 halls (Hall B and Hall C) began malfunctioning. Findings: Review of the facility's policy titled, Call Light System, revealed in part: Purpose: to respond to resident's request and needs. Equipment: Functioning call bell system Procedure: 1. Answer call system promptly .7. If call system is defective, report to maintenance .Essential Points .Should call system malfunction hand bells will be distributed to every resident. 1. Resident #2's electronic medical record was reviewed and revealed the resident was admitted to the facility on [DATE]. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 indicating the resident's cognition was moderately impaired. Under Section GG, Resident #2 was assessed as having impairment on one side of her upper and lower extremities that interfered with daily functions. Resident #2 was also assessed as requiring substantial/maximal assistance when moving from standing position to sitting, transferring from bed to wheelchair, maintaining toileting hygiene and dressing/undressing below the waist. Review of facility's grievance logs from 10/01/2023 thru 12/18/2023 revealed Resident #2's RP filed a grievance on 12/05/2023. Review of Resident #2's filed grievance revealed the resident's RP voiced concerns after reviewing the resident's in room video surveillance on 12/05/2023. The RP discovered that the resident fell and was on the floor for an hour before someone found her. Review of the Investigation findings of the filed grievance revealed the call light system on Hall C was malfunctioning. Review of the facility's I/A (Incidents/Accident) logs from 10/01/2023 thru 12/18/2023 revealed Resident #2 had an unwitnessed fall on 12/05/2023 at 2:30 a.m. Review of Resident #2's I/A investigation revealed the report was prepared by S7LPN (Licensed Practical Nurse) on 12/05/2023 at 2:30 a.m. and included the nursing description that read: Called to resd (resident) room per CNA (Certified Nursing Assistant), Resd noted to be sitting on the floor on buttocks. Head to Toe Assessment done. 0 injuries/discolorations noted. Further review of Resident #2's I/A investigation revealed on 12/06/2023 a note entered by S3ADON (Assistant Director of Nursing) that read in part .Per RP, resident had pressed the call bell but no one came to the room. Issues were happening with the call bell system on Hall C and staff were under the impression that those problems had resolved but they had not, therefore staff was not alerted of the call bell . Resident #2 was unable to be interviewed because she was admitted to the hospital. On 12/18/2023 at 9:33 a.m., a phone interview was conducted with Resident #2's RP. He confirmed that he filed a complaint with the facility about the resident falling after calling for assistance on the early morning of 12/05/2023. Resident #2's RP stated he had reviewed the resident's in room video footage and discovered the resident had pressed her call bell button at 1:34 a.m. and after approximately 30 minutes of not receiving assistance, the resident attempted to get out of bed on her own at 2:02 a.m. and fell on the floor mat on the side of her bed. Resident #2's RP further stated, the resident remained on the floor mat until 2:37 a.m. when S9CNA entered the resident's room. He stated he was informed by S3ADON via phone that the facility's resident call system was down. On 12/18/2023 at 3:50 p.m., an interview was conducted with S5MAINT (Maintenance). S5MAINT stated the nurses on Halls B and C had notified him on the day of 12/04/2023 that the resident call system's boxes located at the nurses stations were making a constant noise with the lights flickering. He then contacted the call system company and stated that later in the evening of 12/04/2023 someone came out and he thought the issue was fixed. S5MAINT stated he was notified the next morning by S3ADON that the resident call system was not working properly on Halls B and C. On 12/19/2023 at 9:09 a.m., a phone interview was conducted with S7LPN. S7LPN stated she worked the night shift (10 p.m.- 6 a.m.) on 12/04/2023 and was the nurse caring for Resident #2. S7LPN confirmed the resident call system was not working properly and explained the main call system box at the nurse's station was not sounding and only the lights would [NAME] if a call light was pressed by a resident. S7LPN denied informing maintenance about the resident call system not working properly and assumed S6LPN had notified maintenance. On 12/19/2023 at 10:28 a.m., an interview was conducted with S6LPN. S6LPN stated she had worked a double shift on 12/04/2023 from 6 a.m.- 10 p.m. on Hall B and confirmed the resident call system was not working properly. S6LPN explained the main call system box at the nurse's station was making a constant beeping noise and the lights on the box would [NAME]. S6LPN stated someone came out and fixed the resident call system by the time she finished her shift on 12/04/2023. On 12/19/2023 at 10:42 a.m., an interview was conducted with S8LPN. S8LPN stated she worked the day shift (6 a.m- 2 p.m.) on Monday 12/04/2023 and Tuesday 12/05/2023. S8LPN stated the resident call system was not working properly on 12/04/2023 and that the main call system box at the nurse's station was making a loud noise that was constant and all the lights on the box would blink very fast. S8LPN stated on 12/04/2023 she notified S5MAINT via text message of the resident call system not working properly and he had contacted the call system company to reset the call system. 2. On 12/19/2023 at 2:45 p.m., a bed alarm was tested in Room A on Hall C with S10CNA. Upon exiting Room A, the dome light located above the outside of the door was observed flickering and S3ADON and S5MAINT were observed at the nurse's station for Hall C. S3ADON stated Room A always acts up and that S5MAINT notified the resident call system company to have a technician come out to the facility to identify the problem. On 12/19/2023 at 3:00 p.m., S3ADON confirmed S5MAINT notified the resident call system company and reported the call system not working properly. S5MAINT then walked up and stated he was waiting for the resident call system commpany to call him back with a time of when a technician could come to the facility. On 12/19/2023 at 3:32 p.m., a phone interview was conducted with S9CNA. S9CNA confirmed she was working on Hall C, the night shift on 12/04/2023. S9CNA stated around 2:30 a.m., S7LPN instructed her to go to Resident #2's room after S7LPN observed the resident's light located above the resident's door was flickering. S9CNA confirmed there was no noise alarming from the resident call system. When she opened the door to the resident's room, she heard the resident's bed alarm alarming and observed the resident on the floor mat near her bed. On 12/19/2023 at 4:42 p.m., a joint interview was conducted with S3ADON and S4AADM/QA (Assistant Administrator and Quality Assurance Nurse). S3ADON confirmed she investigated an incident that happened on 12/05/2023 involving Resident #2 and identified that the resident call system was not working properly. S3ADON stated a technician came to the facility on [DATE] to repair the resident call system and alternative hand held bells were provided to be kept at the nurse's station on 12/06/2023. S3ADON confirmed it was identified after the surveyors tested a bed alarm in Room A on Hall C that the resident call system was not working properly. S4AADM/QA stated she had opened a corrective action plan on 12/05/2023 that identified the call light system problem on Hall C and implemented monitoring of the resident call system on 12/06/2023 that was currently ongoing. Review of the monitoring revealed from 12/06/2023 thru 12/19/2023, revealed Room A had not been monitored. On 12/19/2023 at 5:10 p.m., an interview was conducted with S11Technician and S1ADM (Administrator). S11Technician explained the resident call system first began not working properly on 12/04/2023 involving Hall C which was on a connected network with Hall B. He confirmed the resident call system was a wired system and that Room A has been triggering the malfunctions that started on 12/04/2023. S11Technician stated he has had to come to the facility four additional times from 12/04/2023 thru 12/19/2023 because of the faulty resident call system affecting Halls B and C. S11Technician confirmed each time he has been onsite at the facility, the error involves Room A. S1ADM confirmed the resident call system was not working properly beginning on 12/04/2023 thru present.

Based on observations, interviews, and record review, the facility failed to ensure that each resident's person-centered comprehensive care plan was implemented for 1 (#2) of 3 (#1, #2 and #3) sampled residents by failing to ensure Resident #2 had a working call light and received prompt response when the resident requested assistance. Findings: Resident #2's electronic medical record was reviewed and revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Cerebrovascular Accident (CVA/Stroke), Other Speech Language Deficits following Cerebral Infarction, Cognitive Communication Deficit, Unsteadiness on Feet, Difficulty in Walking and Anxiety Disorder. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 09 indicating the resident's cognition was moderately impaired. Under Section GG, Resident #2 was assessed as having impairment on one side of her upper and lower extremities that interfered with daily functions. Resident #2 was also assessed as requiring substantial/maximal assistance when moving from standing position to sitting, transferring from bed to wheelchair, maintaining toileting hygiene and dressing/undressing below the waist. Review of Resident #2's current care plan revealed the resident was identified as a high risk for falls r/t (related to) impaired mobility, unsteady on feet and hx (history) of CVA with the following pertinent interventions: The resident needs prompt response to all requests for assistance. The resident needs a safe environment .a working and reachable call light . Review of the facility's I/A (Incidents/Accident) logs from 10/01/2023 thru 12/18/2023 revealed Resident #2 had an unwitnessed fall on 12/05/2023 at 2:30 a.m. Review of Resident #2's I/A investigation revealed the report was prepared by S7LPN (Licensed Practical Nurse) on 12/05/2023 at 2:30 a.m. and included the nursing description that read: Called to resd (resident) room per CNA (Certified Nursing Assistant), Resd noted to be sitting on the floor on buttocks. Head to Toe Assessment done. 0 injuries/discolorations noted. Immediate Actions Taken read: Head to toe assessment, Encouraged to call for assistance by using call bell. On 12/19/2023 at 9:09 a.m., a phone interview was conducted with S7LPN. S7LPN stated she worked the night shift (10 p.m.- 6 a.m.) on 12/04/2023 and was the nurse caring for Resident #2. S7LPN further confirmed that the immediate actions taken were not appropriate because the resident's call system was not working properly. On 12/19/2023 at 12:30 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing) who stated she investigated and reviewed all I/A reports. S3ADON confirmed that her investigation revealed staff were not made aware of Resident #2's call bell on the morning of 12/05/2023. On 12/19/2023 at 3:32 p.m., a phone interview was conducted with S9CNA. S9CNA confirmed she was working on Hall C, the night shift on 12/04/2023. S9CNA stated around 2:30 a.m., S7LPN instructed her to go to Resident #2's room because S7LPN observed the resident's light above her room door flickering. S9CNA stated when she opened the resident's door, the resident's bed alarm was beeping and the resident was observed on the floor mat. On 12/19/2023 at 4:42 p.m., a joint interview was conducted with S3ADON and S4AADM/QA (Assistant Administrator and Quality Assurance Nurse). S3ADON confirmed Resident #2's call light was activated on the morning of 12/05/2023 because S7LPN observed the light above the resident's door flickering. S3ADON was unable to verify the timing that the resident's call bell was activated. S4AADM/QA confirmed the resident call system was not working properly on 12/04/2023 and 12/05/2023.

Based on observation, interviews, and record reviews, the facility failed to implement the residents' plan of care by not following physician orders and the care plan for 2 (#16, #105) out of a finalized sample of 38 residents as evidenced by: 1. Failing to ensure catheter tubing was secured by using a leg strap for resident #16, 2. Failing to monitor and document behaviors and adverse reactions to an antidepressant for resident #105. This deficient practice had the potential to affect a total census of 109 residents. Findings: Resident #16 Records review revealed that Resident #16 was admitted on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, Retention of Urine, Urinary Tract Infection Site not specified. A review of Resident #16's Physician's Orders revealed an order dated 02/06/2023 foley leg strap to release tension from foley. A review of Resident #16's Care Plan revealed, in part, indwelling foley catheter related to obstructive and reflux uropathy, interventions leg straps as ordered to keep tension off of catheter. On 07/10/2023 at 10:15 am., an observation of Resident #16, lying in bed asleep. His foley bag was noted with dark urine and no foley leg strap inplace. On 07/10/23 at 12:03 p.m., another observation was conducted of the Resident #16 with no foley leg strap inplace. An interview was conducted with S14LPN (Licensed Practical Nurse). She confirmed the Resident had no foley leg strap inplace, and should have had a leg strap inplace as per the physician orders. 47354 Resident #105 Records review revealed that Resident #105 was admitted on [DATE] with diagnoses that included Major Depressive Disorder. A review of Resident #105's Physician's Orders revealed an order dated 05/19/2023 for Lexapro 10mg (a medications used to treat depression) give 1 tablet via PEG (percutaneous endoscopic gastrostomy) tube one time a day related to Major Depressive Disorder. A review of Resident #105's Care Plan revealed, in part, an intervention to address Resident #105's antidepressant use to monitor/document/report adverse reactions and behaviors to antidepressant therapy. A review of Resident #105's EMAR (Electronic Medication Administration Record) dated for July 2023 revealed the resident received Lexapro 10mg daily as ordered. There was no documentation of adverse reactions/side effects and behavior monitoring for July 2023. On 07/11/2023 at 4:05 p.m., an interview was conducted with S12LPN. S12LPN confirmed that behavior and adverse reaction/side effect monitoring is documented on the EMAR every shift for medications, including antidepressants. On 7/11/2023 at 4:10 p.m., an interview was conducted with S4LPNCP. S4LPNCP confirmed that resident #105 was currently prescribed and taking an antidepressant. She confirmed that an intervention on the residents Care Plan for the use of antidepressant medication required staff to monitor/document/report adverse reactions and behaviors to antidepressant therapy. S4LPNCP confirmed there was no documentation of behavior or adverse reaction monitoring on the EMAR. S4LPNCP stated that the nursing staff should be monitoring for these behaviors and adverse reactions/side effects every shift and this monitoring would be located on the EMAR. On 07/12/2023 at 9:22 a.m., an interview was conducted with S11RNDON. S11RNDON confirmed that documentation for behavior monitoring and adverse reaction monitoring for antidepressants would be located on the EMAR. S11RNDON confirmed that Resident #105 was taking an antidepressant and that Resident #105 had no behavior or adverse reaction monitoring for an antidepressant.

Based on record reviews and interviews the facility failed to ensure a resident was free from accidents hazards during a lift transfer for 1 (#5) of 2 (#3, #5) residents who required two-person transfer with a mechanical (Hoyer) lift, of a total of 5 (#1, #2, #3, #4, and #5) sampled residents. This deficient practice resulted in an actual harm for Resident #5 on 7/6/2022 when S4CNA transferred the resident from a chair to the bed without assistance of another person nor utilizing the mechanical lift, according to the resident's care plan. Resident #5 sustained a fracture to her Left shoulder during the transfer. On 7/7/2022, an x-ray revealed that Resident #5 had an Oblique displaced angulated fracture of the proximal humerus. The resident was transferred to the hospital on 7/7/2022 and underwent surgery for the fractured humerus on 7/8/2022. She was hospitalized from 7/7/2022 until 7/11/2022, when she returned to the facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's policy titled Hoyer Lift was conducted and revealed, in part: Mechanical Lift Policy revealed the following, in part: Purpose- A Hoyer lift enables two people to lift and move contracted, spastic or heavy resident lifting. A review of Resident #5's record revealed an admitted [DATE] with diagnoses including [CONDITION(S)] and [CONDITION(S)] following a [CONDITION(S)] ([CONDITION(S)]/Stroke) to the left non-dominant side, muscle wasting and atrophy bilateral shoulders, left arm and hand, muscle wasting to left leg and right thigh, unsteadiness on feet, and lack of coordination. A diagnosis dated 7/15/2022 of a 2-part displaced fracture of surgical neck of left Humerus was noted. A review of Resident #5's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 3, indicating the resident was severely impaired cognitively. Resident #5 was assessed as 4/3 (total dependence requiring 2 persons assist) for transfers, and 3/3 (extensive assistance required by 2 persons) for Bed Mobility. For chair to bed transfer, Resident #5 was assessed as 01-dependent- helper does all the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required. Further review revealed a discharge MDS (Minimum Data Set) assessments dated 7/7/2022, and a reentry MDS dated [DATE] from an acute hospital. A review of Resident #5's Care Plan revealed: Special instructions: Fall mat on left side of bed, bed mobility = extensive, transfer total with 2 CNAs (Certified Nursing Aides) and lifter. ADL (Activities of Daily Living) self-care performance deficit r/t (related to) recent L (left) Humerus fx (fracture), impaired mobility, [CONDITION(S)]/[CONDITION(S)] following [CONDITION(S)] affecting L non-dominant side, severely impaired cognition. Transfer - the resident requires mechanical lift (Hoyer) with 2 staff assistance for transfers. A review of Resident #5's Progress Notes revealed, in part: 7/7/2022 at 08:00 a.m. - summoned to resident's room per .(S10CNA's name) . I observed a large bruise to left upper arm and a small bruise to her left breast. Assessed. Resident c/o (complains of) pain when left shoulder is touched. Resident states my arm is broke . mobile services notified and will come to facility to x-ray. 7/7/2022 at 11:00 a.m. -x-ray results received via fax . (Physician's name) office notified of abnormal results. 7/7/2022 at 11:20 a.m. - New order noted and carried out to send resident to . (hospital name) to eval and tx (treat) r/t (related to) abnormal results. 7/8/2022 at 09:30 a.m. - Resident admitted to . (hospital name) DX (diagnosis): Left humerus fx (fracture). Resident scheduled for surgery at 11AM today. 7/11/2022 at 5:17 p.m. -Resident returned from . (hospital name). A review of the x-ray report dated 7/7/2022 revealed the following: Indications-pain, bruising. Positive for acute angulated fracture of the proximal shaft of the humerus. Positive for an oblique fracture line that occurs 2 cm distal to the surgical neck. Positive for medical displacement of the distal fragment and a 4-5 cm retraction with overlap. Impression: Oblique displaced angulated fracture of the proximal humerus. A review of the discharge hospital records dated 7/11/2022 at 5:34 p.m., revealed the resident's primary diagnosis was Closed 2-part Displaced Fracture of Surgical Neck of Left Humerus. A review of the facility's Investigation Report revealed, the following: A statement by S12LPN dated 7/7/2022, which read in part: Date of incident 7/6/22 time 8:30 p.m., this nurse noted large discoloration, which was green, blue and purple in color to L (left) upper inner arm into L axilla . A statement by S10CNA dated 7/7/2022, which read in part: Resident #5. Date of incident 7/7/2022. I was bed bath, took shirt off notice her arm, call the nurse .it was not there when bathing her Tuesday [Sic.]. Further review of the Investigation Report revealed in part: S9LPN assessed the area on 7/7/2022 at 7:13 a.m. Resident complained of pain when area was touched. Resident stated to S9LPN my arm is broke. MD notified and order x-ray to Left shoulder and elbow obtained. Further review of the Investigation Report revealed in part: On 7/6/2022 after lunch at 11:59 a.m. resident is brought to her room by S4CNA. S4CNA comes out of the room shortly after without resident. S4CNA interviewed and states that she transferred resident to her bed at that time and changed her. There is no lifter seen going in or out of resident's room. S4CNA states that she did transfer her by herself in the room Resident is checked on by staff multiple times throughout the shift and resident does not exit the room again until the following day . S4CNA dismissed from the facility on 7/7/2022. On 9/6/2022 at11:15 a.m., an observation of Resident #5 sitting at a feeding assistance table in the dining room was made. The resident was using her right hand attempting to feed herself. She was not observed using her left hand during the meal observation. On 9/7/2022 at 9:45 a.m., an observation of Resident #5 sitting in her wheelchair was noted. A Hoyer lifter pad was noted under the resident. Her left arm was resting on arm of her wheelchair, her left leg was extended out in front of resident, with foot turned on its left side resting on the floor. Her right leg was bent at the knee at a 90 degree angle and her foot was planted on the floor. She did not engage with this surveyor. On 9/6/2022 at 12:45 p.m., an interview was conducted with S2DON. She confirmed that S4CNA transferred Resident #5 alone, and without using a lifter on 7/6/2022. She confirmed that on 7/7/2022, Resident #5 was diagnosed with a fracture to her Left Humerus and was sent to the hospital on 7/7/2022, and returned on 7/11/2022 after undergoing surgery to repair the fracture. On 9/7/2022 at 9:50 a.m., an interview was conducted with S10CNA. She stated that on the morning of 7/7/2022 she went to change Resident #5 and get her ready to get out of bed. She stated that when she turned the resident she saw that her left shoulder/arm was swollen. She stated that her arm was not that way when she assisted her on 7/5/2022. On 9/7/2022 at 10:05 a.m., an interview was conducted with S3CNASupervisor She confirmed that S4CNA had conducted a transfer inappropriately on Resident #5 when she transferred her alone and without using a Hoyer lift, in which the resident sustained a fracture to her left humerus. She stated the aide was let go after because of that incident. On 9/7/2022 at 12:45 p.m., an interview was conducted with S9LPN. She stated she worked with Resident #5 often and was familiar with her. She stated that the resident was paralyzed on left side of body, did not have use of her left arm without assistance, and that the resident did not usually complain of pain. S9LPN stated that on 7/7/2022 her shift was 6:00 a.m. to 2:00 p.m., and in the morning S10CNA asked her to have a look at the resident's shoulder as she had found a bruise. She stated that she assessed Resident #5 and found a splotchy bruise on her paralyzed left shoulder, which was on half of her left upper arm, down into her left axilla, and to her left breast area. S9LPN stated that it was an alarming bruise and that Resident #5 told her it was broken, and that the resident winced when the area was palpated. S9LPN stated that received an order from the physician for an x-ray, which revealed that Resident #5's Left humerus was fractured, she was sent to the hospital and underwent surgery for the fracture. On 9/8/2022 at 12:18 p.m., an interview was conducted with S3CNASupervisor. She stated that she was responsible for supervising agency aides to ensure they properly transferred residents using the Hoyer lifter. She stated that S4CNA, an agency CNA (Certified Nursing Assistant) failed to follow Resident #5's care plan by transferring the resident #5 without assistance. On 9/8/2022 at 12:28 p.m., an interview was conducted with S2DON. She stated the CNA Supervisor was ultimately responsible for supervising agency aides and ensuring that they transferred residents using the Hoyer lift, when required. During the survey, multiple CNAs were interviewed regarding the use of a Hoyer lift. All staff interviewed were knowledgeable about the facility's policy that two staff members were required to operate the lift when transferring residents. The staff members stated they had received multiple trainings, including observation by therapy staff while conducting transfers to determine competency, on the proper use of a Hoyer lift. Observations of staff conducting transfers with residents who required the use of the Hoyer lift (the only lift used by the facility for transfers), including Resident #5, were conducted on 9/7/2022 and 9/8/2022. Two staff members performed the transfers safely and appropriately. The facility has implemented the following actions to correct the deficient practice: 7/7/2022- Continuous Quality Assessment and Improvement Corrective Action Plan: 7/7/2022- In-service placed at time clock for all staff to transfer residents appropriately with 2 persons when a Hoyer lift is required. 7/7/2022- In -service conducted with all nursing staff on Hoyer Lift Training, video, handouts, and hands on training with therapy. Monitoring of staff competency performing transfers with Hoyer lift conducted by DON, ADON, and CNA Supervisor: 2 residents daily for 2 weeks, then 2 residents weekly for 2 weeks. Monitoring was conducted appropriately from 7/7/2022 through 8/4/2022. Monitoring tool identified all residents in the facility who required the use of a mechanical lift for transfers.

Based on observations, record review and interview, the facility failed to provide supervision to prevent an avoidable accident for 1 (#4) of 5 (#1, #2, #4, #5, #R1) residents investigated for falls in a final sample of 6 residents by: 1. failing to ensure Resident #4 received 2 person assistance for bed mobility; and 2. failing to ensure roll control bolsters were tightly fastened to Resident #4's bed before providing care. This deficient practice resulted in actual harm on 4/3/2022 when S6CNA provided Resident #4's incontinence care without two-person assistance and without ensuring the roll control bolsters (device attached to Resident #4's bed to prevent falls) were properly secured. Resident #4 fell from his bed at medium height and hit his head on the wheel base of a feeding pump pole resulting in the resident's transfer to the hospital. The hospital's CT (computerized tomography) scan of Resident #4's head revealed left supraorbital frontal scalp and periorbital soft tissue contusion with supraorbital laceration. Resident #4 required 10 sutures to repair a 5 cm laceration to his forehead and was admitted to the hospital for observation due to his head injury Findings: Review of facility policy, Fall Prevention Devices read in part: All nursing staff members must be trained in the safe and proper application of each type of device. The proper application of mechanical supports and the care of the resident requiring such devices must be consistently monitored by the nurse responsible for the resident. Review of Resident #4's clinical record revealed he was admitted to the facility on [DATE] with diagnoses and conditions including [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction affecting the right dominant side, Embolism and [CONDITION(S)] of iliac arteries, Obstructive Sleep Apnea, Dysphagia, Gastrostomy, [CONDITION(S)], Attention and Concentration Deficit, Neurologic Neglect Syndrome, and [CONDITION(S)]. Review of Resident #4's annual MDS (Minimum Data Set) assessment dated [DATE] revealed: a cognitive assessment was not conducted because the resident was rarely/never understood. He had impairment to both sides of his upper and lower extremities and a feeding tube. The resident was always incontinent of bowel and bladder. He was totally dependent on staff and required 2 person assistance with bed mobility (turning side to side), transfers, and toileting. Review of the resident's physician's orders revealed an order dated 3/14/22 for roll control bolsters to prevent rolling out of bed every shift. Review of Resident #4's Care Plan revealed in he was at an increased risk for falls related to impaired mobility, a recent stroke with [CONDITION(S)]/[CONDITION(S)], [CONDITION(S)], major depressive disorder, anxiety, use of [CONDITION(S)] medications, poor eyesight, neurological neglect, [CONDITION(S)], and a history of falls from the bed. Interventions included utilizing devices appropriate to ensure safety (i.e., bed mats, sensor alarms, etc.) Further review of the resident's care plan revealed he had an actual fall on 12/24/21 where he was found on left side of the bed on floor. Interventions included 2 floor mats at the bedside and applying a roll control bolster to prevent falls related to rolling out of bed which was initiated on 3/9/22. Actual fall 4/3/22, interventions included: discontinued low air loss mattress and provided with 42 wide mattress, 2 CNAs to provide assistance with bathing, toileting, bed mobility, transfer with lifter. Staff in-services. S6CNA counseled verbally regarding resident needs 2 CNAs during care and ensure roll control bolsters are properly secured to bed prior to providing care. Review of the resident's MAR (Medication Administration Record) March- April 2022 revealed the nurses documented check marks in boxes to indicate that roll control bolsters were checked every shift (3 times a day) beginning March 14th. Review of the CNA task logs March 1st - current (April 19th) 2022 revealed no documentation that they were checking the roll control bolsters. Review of the resident's progress notes revealed: On 12/24/21, the CNA called S5LPN to Resident #4's room. Resident #4 was found on the floor lying on his left side on the left side of the bed. Discoloration was noted to his left anterior head approximately 4.2 cm x 3 cm. Further review revealed floor mats x2 were placed. Further review of Resident #4's progress notes revealed: On 4/3/22, the nurse was called to Resident #4's room. Upon entering she observed Resident #4 lying on his left side, on the right side of the bed on the floor mat. The bed was at medium height. A small amount of blood was on the floor near his head. One wheel from the peg (feeding pump) pole was under his head. A 2 inch laceration was noted through his left eyebrow and a small laceration was noted to the left side of his nose. Resident #4 left the facility via ambulance for further evaluation at the hospital where he was later admitted for monitoring due to his head injury. Review of the hospital emergency room record dated 4/3/22 revealed the resident presented to the emergency department via ambulance after an apparent fall at the nursing home. Positive for left forehead laceration. On [MEDICATION(S)]. Further review revealed the emergency room doctor repaired the 5cm laceration with 10 interrupted sutures. Review of radiology reports revealed: CT (computerized tomopraphy) scan of the head revealed left supraorbital frontal scalp and periorbital soft tissue contusion with supraorbital laceration. Resident was admitted for observation. On 4/19/22 at 8:26 am, S3DON stated she became the DON (Director of Nursing) in January 2022 after serving as the facility's wound care nurse since November 2021. When Resident #4 fell in December 2021 the former DON held the position. She stated that the staff were not sure how Resident #4 fell as he was bedbound, not able to move much, but was found on the floor. After his fall, a floor mat was placed at each side of his bed. Resident #4's RP communicated her concern for Resident #4's safety and requested side rails to prevent the resident from falling during a care plan meeting in February 2022, but was informed the facility could not use side rails. Roll control bolsters were implemented as a fall precaution instead which were placed on the resident's bed in March 2022. Resident #4 had another fall on 4/3/22 when S6CNA was providing personal care. Per S6CNA's statement the bolster was loose and Resident #4 fell over onto the floor. Resident #4's care plan at that time noted he was 1 person assist for hygiene and bed baths and 2 person assistance for transfers and other assistance. On 4/19/22 at 10:43 am, an observation of the resident's room was made with S5LPN. S5LPN stated Resident #4 was out to the hospital since his fall on 4/3/22. She stated that Resident #4 was approximately 130 pounds, non-verbal, motioned with his hands to communicate, was bed bound, and totally dependent on staff. Floor mats were placed at the bedside after the resident's fall in December. Staff were instructed to place the floor mats over the base of the feeding pump. Roll control bolsters were applied later. An observation of the resident's bed was conducted. Bilateral bolsters observed approx. 6-7 inches high and ½ of the bed in length. The bolsters were attached to each other by 2 straps that went across the surface of the mattress. On 4/19/22 at 11:40 am, a phone interview was conducted with S6CNA who stated that Resident #4 was not cognitive and totally dependent on staff for assistance. He was non-verbal, moaned and motioned with his hands to communicate. He was able to move in bed, but very little. He required staff assistance to turn and position him. Resident #4 fell on [DATE] while she was cleaning him. She explained that Resident #4 had a bowel movement and she was performing incontinence care on the resident alone without assistance from another CNA. She stated that she didn't notice that the bolsters were loose. She proceeded to turn the resident over to his side to clean him, the bolster came half way off the bed and the resident fell over the side of the bed landing on the floor mat. She stated that she could not recall if the floor mat was covering the base of feeding pump pole. The pole was positioned at the head of the bed next to the mat as is normally was. She stated that she did not check to see if the bolsters were tightly secured to the bed before beginning incontinence care. S6CNA further stated that, I should have checked it. She confirmed the resident sustained a laceration to his head, was bleeding and went to the ER for evaluation. She stated that an in-service was conducted with all staff prior to the incident to check the bolsters before providing care and staff signed off on it. She stated that before the resident fell he required 1 person assist for all care except for transfers. She stated that she normally performed incontinence care without assistance from another staff. Review of the facility's in-service training report dated 3/8/22 revealed in part: Resident #R1 now has roll control bolsters on her bed, make sure they are properly secured to her bed before providing care .Do not remove from bed. Staff signatures noted including S5LPN's and S6CNA's signatures. On 4/19/22 at 12:36 p.m., S5LPN stated that the task of checking the bolsters were documented on the MAR daily by the nurses. She stated that she only visually checked Resident #4's bolsters to ensure they were secured to the bed. She denied physically touching or manipulating bolsters to ensure they were tightly fastened. On 4/19/22 at 1:40 pm, during a follow-up interview with S5LPN, she stated that nurses only visualized to see if bolsters were in place, but the CNAs were responsible for ensuring the bolsters were tightly secured to the bed by tugging the bolsters to ensure it is tight each time they went in to provide any care including incontinence care and bed baths. She reviewed the in-service form dated 3/8/22 and stated she remembered that S6CNA was present. S3DON applied bolsters to Resident #R1's bed and showed staff how to check for security and in-serviced on the device. Staff were not in serviced on removing or applying as they were told not to do this. She stated they were not in serviced after the bolsters were placed on Resident #4's bed, but S3DON notified staff of the bolster placement and that if they had any questions to ask S3DON. S5LPN stated she was not sure if the CNAs documented each time they checked the bolsters. On 4/19/22 at 2:19 pm, another interview was conducted with S3DON who stated that all staff listed on the in-service form did not observe her demonstrate how to tighten the straps if bolsters were loose. She stated that S6CNA was not present during demo, but that all CNAs were informed that bolsters were put on and how to check to see if it was secure. Staff CNAs should physically move the bolster to ensure it is secure each time prior to performing any resident care. On 4/19/22 at 2:41 pm, Resident #4's RP stated that after Resident #4's first fall staff were supposed to cover the base of the feeding pump with the floor mat which could have prevented the resident's injury. She stated that the resident could not move and needed 2 staff to care for him. On 4/19/22 at 3:11 pm, an interview was conducted with S3DON who stated that CNAs did not have a task on their kiosk to document they were checking the bolsters. When asked how the facility ensured the CNAs were checking the bolsters, S3DON stated that the floor nurses were responsible for supervising the CNAs and ensuring the CNAs were checking the bolsters properly. She stated the nurses would then document that the bolsters were checked on the MAR. On 4/19/22 at 3:20 pm, an interview was conducted with S4MDS. S4MDS reviewed the CNA task logs documentation for Resident #4 for the look back period 2/22/22 thru 2/28/22 and compared it to Resident's annual MDS assessment dated [DATE]. She stated that according to the look back there was one occurrence where 2 aides provided bed mobility and toileting. Because of this one occurrence, the resident was coded as needed 2 person assistance on his annual MDS. She confirmed that as of 2/28/22 the resident needed 2 staff for bed mobility and toileting which would include turning during incontinence care. On 4/19/22 at 3:57 pm, a review of Resident #4's care plan and annual MDS assessment dated [DATE] was conducted with S3DON. S3DON stated that when she looked at Resident #4'a care plan after the fall on 4/3/22 she noticed his care plan noted 1 person assistance and was not correct. She stated that the resident should have had 2 people assisting him with turns (bed mobility) and toileting (incontinence care) due to his physical limitations. She stated that it didn't make sense that the resident only needed 1 person for these tasks as he was totally dependent. She confirmed that the resident's annual MDS dated [DATE] was coded for 2 person assistance with toilet and bed mobility. S3DON confirmed that S6CNA should not have provided the resident incontinence care alone without assistance, and that S6CNA should have checked the bolsters before providing Resident #4's care.

Based on observation, record review and interview, the facility failed to ensure that each resident received adequate supervision to prevent accidents by leaving a severely cognitively impaired resident (#5) unattended on the toilet in the resident bathroom. Resident #5, who was to have a chair and/or bed alarm on at all times, was left unattended on the toilet, in her bathroom, where she sustained a fall and a fractured hip. Resident #5 was placed on complete bed rest for 4 days following the fall and hip fracture and experienced moderate to severe pain, requiring the use of narcotic pain medications as a result of the deficient practice. This deficient practice affected 1 (#5) out of 5 (#1, #2, #3, #4, #5) of the residents reviewed with falls out of total of 101 residents in the facility. FINDINGS: Resident #5 A review of Resident #5 ' s clinical record revealed that she was a [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #5 ' s Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, which would indicate that she was severely cognitively impaired. A review of Resident #5 ' s Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she was severely impaired cognitively and that her behavior included wandering. Further review of the MDS and Functional Status revealed that she required extensive assistance of one person for Transferring and Toileting. Further review of the MDS revealed that Resident #5 was on no pain medication regimen and had received no pain medications during the look back period. A review of Resident #5 ' s Quarterly MDS and Functional Status dated 2/18/14 (after the fall and hip fracture of 1/8/14) revealed that she required total assistance of two persons for Transferring and total assistance of one person for Toileting. A review of Resident #5 ' s Fall Assessments completed 12/24/13, 12/29/13, and 12/30/13 revealed scores of 12, to indicate that the resident was high risk for falls. A review of Resident #5 ' s Care Plan revealed that she was at risk for falls and that interventions included for staff to assist with transfers and ambulation and for her to have a chair and bed alarm in place for safety with start date of 12/30/13. Further review of Resident #5 ' s Care Plan revealed that she required assistance of cueing and guiding with toileting as she was unable to recall the location of the restroom due to disease process. A review of Resident #5 ' s Incident Notification Form dated 1/18/14 at 4:00 pm revealed that she sustained a fall without injury while using the restroom. Further review of the report revealed that the CNA left the resident to get clothing out of the closet when she heard a thump out of the bathroom. The CNA returned to the bathroom and found Resident #5 on the floor in the bathroom on her buttocks with her back against the wall under the sink. Further review of the report revealed that the resident was assessed, and there were no injuries noted at the time. A review of a Witness Statement dated 1/18/14, completed by the CNA present at the time of the incident, confirmed the details of the incident report as written. Further review revealed that she left the resident on the toilet, in the bathroom, to go the closet to get a pair of pants. A review of an In-Service Training Report revealed that staff were in-serviced, including the CNA involved, about not leaving this resident unattended while toileting. The in-service was noted to be dated 1/8/14 and timed immediately after the incident. A review of Resident #5 ' s Nurse ' s Notes dated 1/18/14 at 5 pm revealed that the resident complained of pain to her right lower back and was administered Narco (narcotic pain medication for moderate to severe pain) as ordered for pain. A review of Resident #5 ' s Nurse ' s Notes dated 1/19/14 at 4 pm revealed that the resident complained of pain when being turned from side to side. Further review revealed that at 4:25 pm the resident was transferred out to the hospital as per physician's order [REDACTED]. A review of Resident #5 ' s Nurse ' s Notes dated 1/19/14 at 9:40 pm revealed that the hospital called in a report to the nursing staff that the resident had a hip fracture and would require complete bed rest. Resident #5 was transferred back to the facility at 10:20 pm that evening. A review of Resident #5 ' s Hospital Emergency Discharge Instructions dated 1/19/14 revealed Final [DIAGNOSES REDACTED]. " A review of Resident #5 ' s January, 2014 Medication Administration Record (MAR) revealed that the resident required 14 doses of the pain medication Narco during the month of January for pain after the fall on 1/18/14 and 8 additional doses of Narco pain medication during the month of February, 2014. Further review of Resident #5 ' s January MAR revealed that the resident was being monitored for the use of a wander guard and a bed and chair and bed alarm every shift prior to the fall on 1/18/14. Resident #5 ' s January MAR also revealed that the resident was placed on complete bed rest as per physician's order [REDACTED]. An observation of Resident #5 on 1/24/14 at 9:15 am revealed that the resident was seated up in her wheelchair in the day room watching television and was not interview able due to cognition. Resident #5 was noted to have foot pedals in the up position on the wheelchair but one foot was noted on the floor. An interview was conducted with S2, DON on 3/25/14 at 9:15 am who confirmed that Resident #5 sustained a fall on 1/18/14 at 4 pm and that S12, CNA left her alone on the toilet while she went to retrieve the resident pants in her closet. S2, DON pointed out that while S12, CNA was out of the bathroom, Resident #5 fell to the floor of the bathroom onto her buttocks and was found there by S12, CNA. She confirmed that Resident #5 had a physician's order [REDACTED]. She added that Resident #5 should not have been left alone unattended on the toilet since she had a history of [REDACTED]. An additional interview was conducted with S2, DON on 3/25/14 at 4:25 pm who stated that she would expect that the standard of practice would be for the CNA to attend the resident throughout the toileting process, especially since this was a resident that was very confused. She added that a resident with a severely impaired judgment, such as this resident, should have been attended constantly while on the toilet. She added that any resident with a chair/bed alarm on should have a staff member with them at all times when off the bed/chair alarm.

Based on observation, record review and interview, the facility failed to ensure that all nurse aides demonstrated competency in skills and techniques necessary to care for residents ' needs, as identified through resident assessments, and described in the plan of care and evidenced by Nurse aide staff leaving a severely cognitively impaired resident (#5) alone and unattended on the toilet in her bathroom. Resident #5, who was to have a chair and/or bed alarm on at all times, was left unattended on the toilet, in her bathroom, where she sustained a fall and a [MEDICAL CONDITION]. Resident #5 was placed on complete bed rest for 4 days, after the fall and [MEDICAL CONDITION], and experienced moderate to severe pain, that required the use of narcotic pain medications as a result of the deficient practice. This deficient practice affected 1 (#5) out of 5 (#1, #2, #3, #4, #5) of the residents reviewed with falls out of total of 101 residents in the facility. FINDINGS: Resident #5 A review of Resident #5 ' s clinical record revealed that she was a [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #5 ' s Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, which would indicate that she was severely cognitively impaired. A review of Resident #5 ' s Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she was severely impaired cognitively and that her behavior included wandering. Further review of the MDS and Functional Status revealed that she required extensive assistance of one person for Transferring and Toileting. Further review of the MDS revealed that Resident #5 was on no pain medication regimen and had received no pain medications during the look back period. A review of Resident #5 ' s Quarterly MDS and Functional Status dated 2/18/14 (after the fall and [MEDICAL CONDITION] of 1/8/14) revealed that she required total assistance of two persons for Transferring and total assistance of one person for Toileting. A review of Resident #5 ' s Fall Assessments completed 12/24/13, 12/29/13, and 12/30/13 revealed scores of 12, to indicate that the resident was high risk for falls. A review of Resident #5 ' s Care Plan revealed that she was at risk for falls and that interventions included for staff to assist with transfers and ambulation and for her to have a chair and bed alarm in place for safety with start date of 12/30/13. Further review of Resident #5 ' s Care Plan revealed that she required assistance of cueing and guiding with toileting as she was unable to recall the location of the restroom due to disease process. A review of Resident #5 ' s Incident Notification Form dated 1/18/14 at 4:00 pm revealed that she sustained a fall without injury while using the restroom. Further review of the report revealed that the CNA left the resident to get clothing out of the closet when she heard a thump out of the bathroom. The CNA returned to the bathroom and found Resident #5 on the floor in the bathroom on her buttocks with her back against the wall under the sink. Further review of the report revealed that the resident was assessed, and there were no injuries noted at the time. A review of a Witness Statement dated 1/18/14, completed by the CNA present at the time of the incident, confirmed the details of the incident report as written. Further review revealed that she left the resident on the toilet, in the bathroom, to go the closet to get a pair of pants. A review of an In-Service Training Report revealed that staff were in-serviced, including the CNA involved, about not leaving this resident unattended while toileting. The in-service was noted to be dated 1/8/14 and timed immediately after the incident. A review of Resident #5 ' s Nurse ' s Notes dated 1/18/14 at 5 pm revealed that the resident complained of pain to her right lower back and was administered Narco (narcotic pain medication for moderate to severe pain) as ordered for pain. A review of Resident #5 ' s Nurse ' s Notes dated 1/19/14 at 4 pm revealed that the resident complained of pain when being turned from side to side. Further review revealed that at 4:25 pm the resident was transferred out to the hospital as per physician's order [REDACTED]. A review of Resident #5 ' s Nurse ' s Notes dated 1/19/14 at 9:40 pm revealed that the hospital called in a report to the nursing staff that the resident had a [MEDICAL CONDITION] and would require complete bed rest. Resident #5 was transferred back to the facility at 10:20 pm that evening. A review of Resident #5 ' s Hospital Emergency Discharge Instructions dated 1/19/14 revealed Final [DIAGNOSES REDACTED]. " A review of Resident #5 ' s January, 2014 Medication Administration Record [REDACTED]. Further review of Resident #5 ' s January MAR indicated [REDACTED]. Resident #5 ' s January MAR indicated [REDACTED]. An observation of Resident #5 on 1/24/14 at 9:15 am revealed that the resident was seated up in her wheelchair in the day room watching television and was not interview able due to cognition. Resident #5 was noted to have foot pedals in the up position on the wheelchair but one foot was noted on the floor. An interview was conducted with S2, DON on 3/25/14 at 9:15 am who confirmed that Resident #5 sustained a fall on 1/18/14 at 4 pm and that S12, CNA left her alone on the toilet while she went to retrieve the resident pants in her closet. S2, DON pointed out that while S12, CNA was out of the bathroom, Resident #5 fell to the floor of the bathroom onto her buttocks and was found there by S12, CNA. She confirmed that Resident #5 had a physician's order [REDACTED]. She added that Resident #5 should not have been left alone unattended on the toilet since she had a history of [REDACTED]. An additional interview was conducted with S2, DON on 3/25/14 at 4:25 pm who stated that she would expect that the standard of practice would be for the CNA to attend the resident throughout the toileting process, especially since this was a resident that was very confused. She added that a resident with a severely impaired judgment, such as this resident, should have been attended constantly while on the toilet. She added that any resident with a chair/bed alarm on should have a staff member with them at all times when off the bed/chair alarm.

Based on record review and interview, the facility was not administered in a manner that enabled it to use its resources effectively to maintain the highest physical well-being of residents for 2 of 8 sample residents (resident #5, resident #6) on [MEDICATION NAME] out of a total of 12 sampled residents and for all residents in the facility on [MEDICATION NAME] therapy (#6 - #21) and any potential new residents admitted that are on [MEDICATION NAME] therapy and for any residents with like first and/or last names (#12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). Administration failed to: 1. develop policies and procedures regarding residents with same first and/or last names and mistaken identity; 2. develop policies and procedures regarding transcription of faxed orders; 3. develop policies and procedure for residents' on high risk drugs, including [MEDICATION NAME], to ensure lab results which monitored the drugs were checked before implementing a change in the dosage of the drug; 4. have a system of quality assurance in place to ensure PT/INR labs were performed as ordered; 5. develop and implement a system of clinical supervision and quality assurance to ensure nurses continued to follow basis nursing safety practices for transcription of faxed orders, high risk drugs such as [MEDICATION NAME], changes in medication without original physicians' orders on the chart; 6. include in policy and procedure on consulting resident's attending physician to include physician attending resident while in the hospital. Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician order [REDACTED]. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's orders [REDACTED].#6 to a Telephone Order Form for resident #5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled physician's orders [REDACTED]. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. On [DATE], the facility discovered the [MEDICATION NAME] error for resident #5 and the resident was in Immediate Jeopardy when the failed failed to immediately consult with the physician caring for the resident at the hospital and inform him of the significant [MEDICATION NAME] error. The Immediate Jeopardy was removed for resident #5 when she died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders [REDACTED]. An onsite visit was conducted on [DATE]. This survey determined that the Immediate Jeopardy situation was removed on [DATE]. The deficient practice continues at an actual harm for resident #5 and a potential for more than minimal harm for residents #6 thru #21. Findings: The facility failed to consult with the hospital physician caring for the resident immediately upon finding a significant [MEDICATION NAME] error. Cross refer to F157 The facility failed to give [MEDICATION NAME] as ordered. Cross refer to F282 The facility failed to ensure residents maintained their highest level of well-being. Cross refer to F309 The facility failed to prevent significant medication errors. Cross refer to F333 The facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and administering of all drugs and biologicals to meet the needs of each resident. Cross refer to F425

Based on record review and interview, the facility was not administered in a manner that enabled it to use its resources effectively to maintain the highest physical well-being of residents for 2 of 8 sample residents (resident #5, resident #6) on [MEDICATION NAME] out of a total of 12 sampled residents and for all residents in the facility on [MEDICATION NAME] therapy (#6 - #21) and any potential new residents admitted that are on [MEDICATION NAME] therapy and for any residents with like first and/or last names (#12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). Administration failed to: 1. develop policies and procedures regarding residents with same first and/or last names and mistaken identity; 2. develop policies and procedures regarding transcription of faxed orders; 3. develop policies and procedure for residents' on high risk drugs, including [MEDICATION NAME], to ensure lab results which monitored the drugs were checked before implementing a change in the dosage of the drug; 4. have a system of quality assurance in place to ensure PT/INR labs were performed as ordered; 5. develop and implement a system of clinical supervision and quality assurance to ensure nurses continued to follow basis nursing safety practices for transcription of faxed orders, high risk drugs such as [MEDICATION NAME], changes in medication without original physicians' orders on the chart; 6. include in policy and procedure on consulting resident's attending physician to include physician attending resident while in the hospital. Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician order [REDACTED]. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's orders [REDACTED].#5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled physician's orders [REDACTED]. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. On [DATE], the facility discovered the [MEDICATION NAME] error for resident #5 and the resident was in Immediate Jeopardy when the failed failed to immediately consult with the physician caring for the resident at the hospital and inform him of the significant [MEDICATION NAME] error. The Immediate Jeopardy was removed for resident #5 when she died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders [REDACTED]. Findings: The facility failed to consult with the hospital physician caring for the resident immediately upon finding a significant [MEDICATION NAME] error. Cross refer to F157 The facility failed to give [MEDICATION NAME] as ordered. Cross refer to F282 The facility failed to ensure residents maintained their highest level of well-being. Cross refer to F309 The facility failed to prevent significant medication errors. Cross refer to F333 The facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and administering of all drugs and biologicals to meet the needs of each resident. Cross refer to F425

Based on record review and interview, the facility failed to inform the family and consult with the physician caring for the resident at the hospital when the facility discovered a resident received an incorrect increase in dosage of [MEDICATION NAME] ([MEDICATION NAME]), a blood thinner, intended for another resident for 1 of 8 sampled residents on [MEDICATION NAME] out of a total sample of 12 sampled residents.( Resident #5). The facility also failed to notify the physician that the [DATE] PT/INR for resident #5 had not been done and failed to notify resident #5's family when the [MEDICATION NAME] error was discovered. Resident #5's Physician order [REDACTED]. On [DATE] S3 LPN transcribed a physician's orders [REDACTED].#5. On [DATE], S3 LPN faxed the order to the pharmacy, the pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect dose and received a substantial increase in [MEDICATION NAME]. Resident #5 received a total of 4 doses of [MEDICATION NAME] 5mg and a total of 9 doses of [MEDICATION NAME] 4 mg which was intended for Resident #6. Resident #5 was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. On [DATE], the facility discovered the [MEDICATION NAME] error for resident #5 and the resident was in Immediate Jeopardy when the facility failed to immediately consult with the physician caring for the resident at the hospital and inform him of the [MEDICATION NAME] error. The Immediate Jeopardy was removed for resident #5 when she died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) who could receive, in error, an increase in dosage of [MEDICATION NAME] and be hospitalized . The Immediate Jeopardy continues as the facility failed to put system in place to ensure the deficient practice does not reoccur. Findings: Resident #5: This resident is a [AGE] year old female who was diagnosed with [REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. A review of Resident #5's Physician order [REDACTED]. Record review revealed on the December, 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the telephone order for [MEDICATION NAME] dated [DATE] at 4:30 PM on Resident #5's chart. S3,LPN stated she transferred the new [MEDICATION NAME] order which was intended for Resident #6 to Resident #5 's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new [MEDICATION NAME] order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN also verified that the PT/INR Lab Results Form with the new [MEDICATION NAME] order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name and when she saw the Lab Results Form (with the [MEDICATION NAME] order on it) she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. Continued review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8pm which read: resident has MD appointment in am due to rectal bleeding, family notified, family member will attend with resident, which was signed by S3 LPN. During the interview process, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify them of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9 pm an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. According to the hospital's emergency room Record dated [DATE], Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview with S1 Interim Administrator on [DATE] at 11:35 am was conducted. During this interview, S1 Interim Administrator confirmed that a significant medication error was discovered for Resident #5 on [DATE] after she received a call from the primary physician office confirming the [MEDICATION NAME] dosage for Resident #5. When reviewing Resident #5's clinical record, S1 Interim Administrator stated she was unable to find supporting lab work to warrant the change in [MEDICATION NAME] dosage and after continuing investigation, it was discovered the Resident #5 received an increase in [MEDICATION NAME] that was intended for Resident #6. After completing the investigation, S1 Interim Administrator stated she then notified Resident #5's Primary Physician on [DATE] of the possible drug error as per their protocol however she stated she did not notify the hospital as she felt notifying the primary physician was sufficient. S1 Interim Administrator also confirmed that the family was not notified of the medication error until [DATE] due to the resident's demise and funeral. S1 Interim Administrator stated she felt prior to this date ([DATE]), it was an inappropriate time to discuss the issue of a medication error involving Resident #5. According to the Louisiana Organ Procurement Agency's Notification of Death Form, Resident # 5 expired on [DATE] at 14:21 with cause of death listed as [MEDICATION NAME] Toxicity.

Based on record review and interview, the facility failed to follow physician's orders by failing to perform a monthly PT/INR lab for December, 2010 for 2 of 12 sampled residents (Resident #5,#10) and failing to give the correct dose of [MEDICATION NAME] per physician's orders (#5) to 1 of 8 sample residents (resident #5) on [MEDICATION NAME] out of a total of 12 sampled residents and for all residents in the facility on [MEDICATION NAME] therapy (#6 - #21) and any potential new residents admitted that are on [MEDICATION NAME] therapy and any residents with like first and/or last names (#12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). For resident #5, the facility failed to: 1. ensure that a [MEDICATION NAME] order for Resident #6 was not transcribed for Resident #5; 2. ensure a faxed order for resident #6 was not documented as a telephone order for resident #5; 3. ensure that orders written on a Telephone Order Form included information that ensured the Telephone Order could be traced back to the original written order; 4. have a quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of [MEDICATION NAME]; 5. ensure that a current PT/INR was drawn and filed on the medical record and reviewed to confirm the need for a [MEDICATION NAME] order adjustment prior to the administration of a new increase in dosage of [MEDICATION NAME]; 6. ensure that residents with like names (first and/or last) were not given another resident's medication; 7. have a quality assurance system in place to daily reconcile new orders for [MEDICATION NAME] by reviewing the new [MEDICATION NAME] order along with the most current PT/INR results to validate the change in dosage of [MEDICATION NAME]; 8. ensure that monthly reconciliation of orders was thorough and accurate by reviewing the new [MEDICATION NAME] order along with the most current PT/INR Lab Results to validate the change in dosage of [MEDICATION NAME] and to identify errors in transcription; 9. ensure that the monthly reconciliation of orders, including review of the MAR, was thorough and accurate and identified errors in transcription. Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician Order was for [MEDICATION NAME] 1 milligram(mg) by mouth on Tuesday, Wednesday, Friday, Saturday and Sunday and [MEDICATION NAME] 2 milligram on Monday and Thursday. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's order written on a PT/INR Lab Results Form for resident #6 to a Telephone Order Form for resident #5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled Physician's Orders and the MARs at the beginning of [DATE] and failed to discover the significant medication error. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. Resident #5 died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders were in place for residents with like first and/or last names; and that reconciliation of new orders on a month to month basis are thorough and accurate. Findings: Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. [MEDICATION NAME] time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as [MEDICATION NAME] ([MEDICATION NAME]). PT/INR test are performed to make sure that the [MEDICATION NAME] is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of resident #5's PT/INR Results Lab Form dated [DATE] revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated [DATE] revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician Orders dated [DATE] revealed [MEDICATION NAME] 1 milligram(mg) by mouth on Tuesday, Wednesday, Friday, Saturday and Sunday and [MEDICATION NAME] 2 milligram on Monday and Thursday with a repeat PT/INR in 4 weeks ([DATE]). A review of Resident #5's PT/INR Lab Results Form dated [DATE] revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician Orders for Resident #5 revealed no changes in the dosages of [MEDICATION NAME]. Review of the resident's clinical record failed to reveal a PT/INR lab result for [DATE], 4 weeks from [DATE]. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The Telephone Order Form revealed the order was written for resident #5. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the Telephone Order for [MEDICATION NAME] dated [DATE] at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new [MEDICATION NAME] order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new [MEDICATION NAME] order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, which had resident #6's name typed on it, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new [MEDICATION NAME] order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the [MEDICATION NAME] order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated [DATE] had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new [MEDICATION NAME] order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under [DATE] were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on [DATE], she initialed that Resident #5 had received [MEDICATION NAME] 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on [DATE] and [DATE] to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on [DATE] Resident #5 received the first dose of [MEDICATION NAME] which was from resident #6's [MEDICATION NAME] order that was written on [DATE]. S3LPN confirmed that Resident #5 received a total of 4 doses of [MEDICATION NAME] 5mg and a total of 8 doses of [MEDICATION NAME] 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated [DATE] and this was verified by S3 LPN. Record review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the [DATE] 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room Record dated [DATE] revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview was conducted with S1 Interim Administrator on [DATE] at 11:35 am. During this interview, S1 Interim Administrator confirmed that a significant medication error was discovered with Resident #5 on [DATE] after receiving a call from the primary physician's office confirming the [MEDICATION NAME] dosage for Resident #5. When reviewing Resident #5's clinical record, S1 Interim Administrator stated she was unable to find supporting lab work to warrant the change in [MEDICATION NAME] dosage and after continuing investigation, it was discovered that Resident #5 received an increase in [MEDICATION NAME] that was intended for Resident #6. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on [DATE] at 14:21 with cause of death listed as [MEDICATION NAME] Toxicity. 2. Resident #10: A review of the clinical record for Resident #10 revealed cumulative [DIAGNOSES REDACTED]. A review of the December, 2010 Physician Orders revealed an order for [REDACTED]. A review of Resident #10's clinical record failed to find a December PT/INR result. An interview was conducted with S2RNDON on [DATE] at 12:45pm was conducted. During this interview, S2DON confirmed that a PT/INR had not been drawn for Resident #10 for the month of December, 2010 as was ordered by the Physician.

Based on record review and interview, the facility failed to follow physician's orders by failing to perform a monthly PT/INR lab for December, 2010 for 2 of 12 sampled residents (Resident #5,#10) and failing to give the correct dose of [MEDICATION NAME] per physician's orders (#5) to 1 of 8 sample residents (resident #5) on [MEDICATION NAME] out of a total of 12 sampled residents and for all residents in the facility on [MEDICATION NAME] therapy (#6 - #21) and any potential new residents admitted that are on [MEDICATION NAME] therapy and any residents with like first and/or last names (#12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). For resident #5, the facility failed to: 1. ensure that a [MEDICATION NAME] order for Resident #6 was not transcribed for Resident #5; 2. ensure a faxed order for resident #6 was not documented as a telephone order for resident #5; 3. ensure that orders written on a Telephone Order Form included information that ensured the Telephone Order could be traced back to the original written order; 4. have a quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of [MEDICATION NAME]; 5. ensure that a current PT/INR was drawn and filed on the medical record and reviewed to confirm the need for a [MEDICATION NAME] order adjustment prior to the administration of a new increase in dosage of [MEDICATION NAME]; 6. ensure that residents with like names (first and/or last) were not given another resident's medication; 7. have a quality assurance system in place to daily reconcile new orders for [MEDICATION NAME] by reviewing the new [MEDICATION NAME] order along with the most current PT/INR results to validate the change in dosage of [MEDICATION NAME]; 8. ensure that monthly reconciliation of orders was thorough and accurate by reviewing the new [MEDICATION NAME] order along with the most current PT/INR Lab Results to validate the change in dosage of [MEDICATION NAME] and to identify errors in transcription; 9. ensure that the monthly reconciliation of orders, including review of the MAR, was thorough and accurate and identified errors in transcription. Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician Order was for [MEDICATION NAME] 1 milligram(mg) by mouth on Tuesday, Wednesday, Friday, Saturday and Sunday and [MEDICATION NAME] 2 milligram on Monday and Thursday. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's order written on a PT/INR Lab Results Form for resident #6 to a Telephone Order Form for resident #5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled Physician's Orders and the MARs at the beginning of [DATE] and failed to discover the significant medication error. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. Resident #5 died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders were in place for residents with like first and/or last names; and that reconciliation of new orders on a month to month basis are thorough and accurate. An onsite visit was conducted on [DATE]. This survey determined that the Immediate Jeopardy situation was removed on [DATE]. The deficient practice continues at an actual harm for resident #5 and a potential for more than minimal harm for residents #6 thru #21. Findings: Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. [MEDICATION NAME] time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as [MEDICATION NAME] ([MEDICATION NAME]). PT/INR test are performed to make sure that the [MEDICATION NAME] is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of resident #5's PT/INR Results Lab Form dated [DATE] revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated [DATE] revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician Orders dated [DATE] revealed [MEDICATION NAME] 1 milligram(mg) by mouth on Tuesday, Wednesday, Friday, Saturday and Sunday and [MEDICATION NAME] 2 milligram on Monday and Thursday with a repeat PT/INR in 4 weeks ([DATE]). A review of Resident #5's PT/INR Lab Results Form dated [DATE] revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician Orders for Resident #5 revealed no changes in the dosages of [MEDICATION NAME]. Review of the resident's clinical record failed to reveal a PT/INR lab result for [DATE], 4 weeks from [DATE]. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The Telephone Order Form revealed the order was written for resident #5. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the Telephone Order for [MEDICATION NAME] dated [DATE] at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new [MEDICATION NAME] order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new [MEDICATION NAME] order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, which had resident #6's name typed on it, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new [MEDICATION NAME] order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the [MEDICATION NAME] order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated [DATE] had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new [MEDICATION NAME] order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under [DATE] were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on [DATE], she initialed that Resident #5 had received [MEDICATION NAME] 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on [DATE] and [DATE] to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on [DATE] Resident #5 received the first dose of [MEDICATION NAME] which was from resident #6's [MEDICATION NAME] order that was written on [DATE]. S3LPN confirmed that Resident #5 received a total of 4 doses of [MEDICATION NAME] 5mg and a total of 8 doses of [MEDICATION NAME] 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated [DATE] and this was verified by S3 LPN. Record review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the [DATE] 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room Record dated [DATE] revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview was conducted with S1 Interim Administrator on [DATE] at 11:35 am. During this interview, S1 Interim Administrator confirmed that a significant medication error was discovered with Resident #5 on [DATE] after receiving a call from the primary physician's office confirming the [MEDICATION NAME] dosage for Resident #5. When reviewing Resident #5's clinical record, S1 Interim Administrator stated she was unable to find supporting lab work to warrant the change in [MEDICATION NAME] dosage and after continuing investigation, it was discovered that Resident #5 received an increase in [MEDICATION NAME] that was intended for Resident #6. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on [DATE] at 14:21 with cause of death listed as [MEDICATION NAME] Toxicity. An onsite visit was conducted on [DATE]. This survey determined that the Immediate Jeopardy situation was removed on [DATE]. The deficient practice continues at an actual harm for resident #5 and a potential for more than minimal harm for residents #6 thru #21. 2. Resident #10: A review of the clinical record for Resident #10 revealed cumulative [DIAGNOSES REDACTED]. A review of the December, 2010 Physician Orders revealed an order for [REDACTED]. A review of Resident #10's clinical record failed to find a December PT/INR result. An interview was conducted with S2RNDON on [DATE] at 12:45pm was conducted. During this interview, S2DON confirmed that a PT/INR had not been drawn for Resident #10 for the month of December, 2010 as was ordered by the Physician.

Based on record review and interview, the facility failed to assure that each resident receives the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for 2 of 8 sample residents (resident #5, resident #6) on [MEDICATION NAME] out of a total of 12 sampled residents and for all residents in the facility on [MEDICATION NAME] therapy (#7 - #21) and any potential new residents admitted that are on [MEDICATION NAME] therapy and any residents with like first and/or last names (#5, #6, #12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). The facility failed to: 1. ensure that a [MEDICATION NAME] order for Resident #6 was not transcribed for Resident #5; 2. ensure a faxed order for resident #6 was not documented as a telephone order for resident #5; 3. ensure that orders written on a Telephone Order Form included information that ensured the Telephone Order could be traced back to the original written order (#5); 4. have a quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of [MEDICATION NAME] (#5); 5. ensure that a current PT/INR was drawn and filed on the medical record and reviewed to confirm the need for a [MEDICATION NAME] order adjustment prior to the administration of a new increase in dosage of [MEDICATION NAME] (#5); 6. ensure that residents with like names (first and/or last) were not given another resident's medication (#5); 7. immediately notify the physician caring for resident #5 at the hospital and notify the family immediately upon discovery of a significant [MEDICATION NAME] medication error which resulted in hospitalization of the resident (#5); 8. have a quality assurance system in place to daily reconcile new orders for [MEDICATION NAME] by reviewing the new [MEDICATION NAME] order along with the most current PT/INR results to validate the change in dosage of [MEDICATION NAME] (#5); 9. ensure that monthly reconciliation of orders was thorough and accurate by reviewing the new [MEDICATION NAME] order along with the most current PT/INR Lab Results to validate the change in dosage of [MEDICATION NAME] and to identify errors in transcription (#5); 10. ensure that the monthly reconciliation of orders, including review of the MAR, was thorough and accurate and identified errors in transcription (#5). 11. ensure an LPN searched to find the order for an increase in the dose of [MEDICATION NAME] for a resident upon finding new Medication packages of [MEDICATION NAME] with increased doses and no new [MEDICATION NAME] order on the chart (#6); 12. ensure LPNs were instructed to alert the DON/Administrator when the pharmacy sent new medication packages of [MEDICATION NAME] at an increased dose and no order was on the chart (#6). Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician order [REDACTED]. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's orders [REDACTED].#6 to a Telephone Order Form for resident #5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled physician's orders [REDACTED]. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. On [DATE], the facility discovered the [MEDICATION NAME] error for resident #5 and the resident was in Immediate Jeopardy when the facility failed to immediately consult with the physician caring for the resident at the hospital and inform him of the significant [MEDICATION NAME] error. The Immediate Jeopardy was removed for resident #5 when she died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders [REDACTED]. Findings: Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. [MEDICATION NAME] time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as [MEDICATION NAME] ([MEDICATION NAME]). PT/INR test are performed to make sure that the [MEDICATION NAME] is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of resident #5's PT/INR Results Lab Form dated [DATE] revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated [DATE] revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician order [REDACTED]. A review of Resident #5's PT/INR Lab Results Form dated [DATE] revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician order [REDACTED]. Review of the resident's clinical record failed to reveal a PT/INR lab result for [DATE], 4 weeks from [DATE]. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The Telephone Order Form revealed the order was written for resident #5. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the Telephone Order for [MEDICATION NAME] dated [DATE] at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new [MEDICATION NAME] order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new [MEDICATION NAME] order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, which had resident #6's name typed on it, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new [MEDICATION NAME] order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the [MEDICATION NAME] order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated [DATE] had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new [MEDICATION NAME] order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under [DATE] were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on [DATE], she initialed that Resident #5 had received [MEDICATION NAME] 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on [DATE] and [DATE] to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on [DATE] Resident #5 received the first dose of [MEDICATION NAME] which was from resident #6's [MEDICATION NAME] order that was written on [DATE]. S3LPN confirmed that Resident #5 received a total of 4 doses of [MEDICATION NAME] 5mg and a total of 8 doses of [MEDICATION NAME] 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated [DATE] and this was verified by S3 LPN. A review of Resident #5's Drug Regimen Review revealed that the Pharmacist reviewed the clinical record on [DATE] and had no recommendations at this time. A phone interview was conducted on [DATE] at 11:45am with S6 Pharmacist. During this interview, S6 Pharmacist said he comes into the facility on a monthly basis and that his last visit to the facility was on [DATE] and that he reviews all resident records when he comes in. When he comes in, his period of review covers from his last visit to the day he re-enters. S6 Pharmacist states that his review includes MARS, treatment sheets, all orders from previous visit to current visit and any pertinent labs. He said he reviews every resident in the facility. He said to assure he covers everyone, he uses his roster and compares it to the facility's current roster so he can be sure to capture new admits or readmits, etc. He said he did review resident #5's record and no recommendations were made in [DATE]. He stated he did not recall if there was a December PT/INR on this resident as the facility still had 8 days to perform one so he looked at the previous lab value. He stated he did capture the new orders for a change in [MEDICATION NAME] for resident #5 that was written on [DATE] and did not question the dose increase as it was very common to have frequent and large dosage changes depending on what was going on with the resident. He said when he does a review, he looks for red flags such as a previous PT/INR done prior to change and if the PT/INR was greater than 3.0. He said that some labs are done at MD office or lab office and is not on the chart yet. He again said he could not recall if a December PT/INR was on the chart but he wasn't concerned and it is not unusual to have frequent changes in [MEDICATION NAME]. When asked if he was not concerned with the fact that resident #5 had been stable with her PT/INR results for the last three months on [MEDICATION NAME] 1 mg. and 2 mg and now had a new order for [MEDICATION NAME] 4 mg and 5 mg which was double the previous dose ordered, he said he wasn't concerned as to the fact that people on [MEDICATION NAME] have frequent dose changes. Record review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the [DATE] 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room Record dated [DATE] revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview was conducted on [DATE] at 11:35 am with S1, Interim Administrator. S1 Interim Administrator stated that she was informed of Resident #5's [DATE] hospital admit for a suspected GI bleed during the morning meeting that was held on [DATE]. S1, Interim Administrator stated on [DATE], while she was sitting at the Central Desk Nurse's Station, Resident #5's doctor's office called to confirm the current dose of [MEDICATION NAME] being given to Resident #5. She said she then pulled Resident #5's medical record, told her the current dose and hung up the phone. S1, Interim Administrator stated that she noticed that the current [MEDICATION NAME] dose was a new hand written order and that her last PT/INR was done in November, 2010, and was not an abnormal lab. S1, Interim Administrator stated that she did not understand why the dosage of [MEDICATION NAME] had been changed for Resident #5 and she suspected something was suspicious because Resident #5 had been admitted with a GI bleed and had a hand written [MEDICATION NAME] order. S1, Interim Administrator wanted to know what the PT/INR results were to cause a change in the [MEDICATION NAME] dosage, so she called a member of the facility's medical records staff who oversees that labs are ordered and the lab results are filed and asked about Resident #5's PT/INR results that should have been drawn on [DATE]. The member of the facility's medical record staff told S1, Interim Administrator that no labs were drawn on Resident #5. S1, Interim Administrator then asked for a list of residents that had labs drawn from [DATE] though [DATE] for any residents that had a PT/ INR drawn during that time period. S1, Interim Administrator noticed that Resident #6 did have a PT/ INR drawn on [DATE]. S1, Interim Administrator then informed the DON that she felt something was not right with the [MEDICATION NAME] order on Resident #5's medical record. S1, Interim Administrator looked at Resident #6's medical record and noticed the new [MEDICATION NAME] order written on Resident # 6's PT/INR Lab Report Form dated [DATE] was the same [MEDICATION NAME] dose as Resident #5's handwritten order. She then said it was strange that S3, LPN, who never worked on the South Hall and is never assigned to Resident #6 but is assigned to Resident #5, had taken off the order for Resident #6. S1, Interim Administrator then said that when she questioned S3, LPN on [DATE], S3LPN confirmed that she had gotten the order to increase Resident #5's [MEDICATION NAME] from that PT/INR Lab Report Form and then S1, Interim Administrator pointed out that the name on the top of the PT/INR Lab Form was Resident #6's , not Resident #5's. S3, LPN then admitted that she must have only looked at the first name and written the order on the wrong chart. S1, Interim Administrator stated that she attempted to call the attending physician's office on [DATE], but they were closed already. On [DATE], S1, Interim Administrator called again for the attending physician and was told that he was out of the office. S1 Interim Administrator stated she then called the primary physicians wife and asked her to have him call the facility when she heard from him. S1, Interim Administrator stated that the attending physician called her late afternoon on [DATE] and she notified him of the transcription error and what she suspected had happened in regard to Resident #5's [MEDICATION NAME] order. According to S1, Interim Administrator, he thanked her for letting him know. S1, Interim Administrator stated she didn't think of letting the hospital know about the error since she had let the attending physician know about both of his patients at the nursing home. She further stated that she did not even think about calling the hospital because the attending physician was made aware. S1 Interim Administrator also confirmed that the family was not notified of the medication error until [DATE] due to the resident's demise and funeral. S1 Interim Administrator stated she felt prior to this date ([DATE]), it was an inappropriate time to discuss the issue of a medication error involving Resident #5. During the interview with S1, Interim Administrator, when asked if the Pharmacist had been notified of the medication error at this time, S1, Interim Administrator and S2, DON stated that he had not been notified as of [DATE] at 11:45 am. A review of the Pharmacy Policy and Procedure Manuel Subject: Medication Errors and Adverse Reaction procedure reads : The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions. S1, Interim Administrator stated that all faxes go to the main fax machine located at the West Desk Nurse's Station and then are brought to the Nurse's Station that the resident belongs to. S1, Interim Administrator confirmed that the facility does not have a specific place to put the orders, but she thinks they put them by the phone, somewhere for nurses to see. S1, Interim Administrator confirmed that there is no policy for faxes received, no policy on transcription of physician orders, and no policy for resident's on high risk drugs. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on [DATE] at 14:21 with cause of death listed as [MEDICATION NAME] Toxicity. During an interview with S2, DON on [DATE] at 9:30 am regarding the name alert stickers that had been placed on the resident's medical records during the survey, she stated "We did not know we had the name alert stickers, but we found them yesterday so we started using them facility wide." 2. Resident # 6: A review of the clinical record revealed cumulative [DIAGNOSES REDACTED]. A review of the December, 2010 Physician Telephone Orders revealed a new Physician's Telephone Order Form dated [DATE] for [MEDICATION NAME] 4 mg po everyday except Monday and Thursday and [MEDICATION NAME] 5 mg po on Monday and Thursday for resident #6. An interview with S4 LPN was conducted on [DATE] at 2:25pm. During this interview, the S4 LPN stated that she wrote the new order shortly after she arrived to work on [DATE] when she found the resident's 4 mg. and 5 mg. [MEDICATION NAME] medications on the counter but could not find the order for the new medication dosage. S4 LPN stated that she remembered she had to call the primary physician to clarify the change in dosage for the [MEDICATION NAME] for this resident. S4 LPN confirmed that the date she wrote the new order for [MEDICATION NAME] was [DATE], and not [DATE] as was documented on the Physician's Telephone Order Form. S4LPN stated she must of thought it was the 20th but she did not work the 20th. She said the sticker for the refill date from the pharmacy was the 21st as well. This was verified by the label on the medication packages presented by the facility. S1, Interim Administrator confirmed that there is no policy for faxes received, no policy on transcription of physician orders, and no policy for resident's on high risk drugs.

Based on interview and record reviews, the Pharmacist failed to identify irregularities and report irregularities to the Director of Nursing and the attending Physician for 1 of 8 sample residents on Coumadin out of a total of 12 sampled residents by failing to collect and analyze diagnostic PT/INR test results and compare to baseline data in order to support a substantial increase in the dose of Coumadin for resident #5. The facility failed to ensure the Pharmacist: 1. thoroughly evaluated the Coumadin medication regimen and Coumadin diagnostic lab testing for resident #5 by failing to determine what the substantial increase in the Coumadin dose for resident #5 was based on; 2. monitor for irregularities by determining if PT/INR labs were completed as ordered to monitor Coumadin therapy; 3. report an irregularity regarding an order for [REDACTED]. Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. On [DATE], the physician faxed an order to increase the Coumadin order for resident #6. The physician's orders [REDACTED].#6. The nurse transcribed this Coumadin order for resident #6 onto a Telephone Order for Resident #5. Resident #5 was placed in Immediate Jeopardy on [DATE] when the pharmacist failed to monitor for current labs associated with Coumadin therapy and failed to address an order for [REDACTED]. stable. A PT/INR test was ordered for [DATE] for resident #5. The resident was given the incorrect dose and received a substantial increase in Coumadin. Resident #5 received a total of 4 doses of Coumadin 5mg and a total of 8 doses of Coumadin 4 mg which was intended for Resident #6, with first dose being given on [DATE]. The pharmacist conducted his drug regimen review on [DATE], one day prior to the first increased dose of Coumadin being given. The Immediate Jeopardy was removed for Resident #5 when the resident was hospitalized on [DATE] with severe abdominal pain and heavy rectal bleeding secondary to Coumadin Toxicity as per the emergency room record. Resident #5 died on [DATE] from Coumadin toxicity. The Immediate Jeopardy continues for all residents in the facility and any potential residents on Coumadin therapy (#6 thru #21) and with like first and/or last names (#12, #13). The pharmacist failed to put a system in place to ensure that current labs for Coumadin therapy would be part of the monthly drug regimen reviews and adequate indications for a Coumadin dose increase would be identified in the drug regimen reviews. Findings: According to the current Consultant Pharmacist Contract between the facility and healthcare agency signed [DATE], the Consultant Pharmacist provides consultant pharmacist services, including but not limited to the following: f. Communicating to the responsible physician potential or actual problems detected relating to medication therapy orders. g. Reviewing medication administration records (MARs) and physician orders [REDACTED]. Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. Prothrombin time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as warfarin (Coumadin). PT/INR test are performed to make sure that the Coumadin is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of a PT/INR Results Lab Form dated [DATE] revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated [DATE] revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician order [REDACTED]. A review of Resident #5's PT/INR Lab Results Form dated [DATE] revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician order [REDACTED]. Review of the resident's clinical record failed to reveal a PT/INR lab result for [DATE], 4 weeks from [DATE]. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The order was written for resident #5. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the telephone order for Warfarin dated [DATE] at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new Warfarin order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new Warfarin order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new Warfarin order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the Warfarin order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated [DATE] had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new Warfarin order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under [DATE] were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on [DATE], she initialed that Resident #5 had received Warfarin 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on [DATE] and [DATE] to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on [DATE] Resident #5 received the first dose of Coumadin which was from resident #6's Coumadin order that was written on [DATE]. S3LPN confirmed that Resident #5 received a total of 4 doses of Coumadin 5mg and a total of 8 doses of Coumadin 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated [DATE] and this was verified by S3 LPN. A review of Resident #5's Drug Regimen Review revealed that the Pharmacist reviewed the clinical record on [DATE] and had no recommendations at this time. A phone interview was conducted on [DATE] at 11:45am with S6 Pharmacist. During this interview, S6 Pharmacist said he comes into the facility on a monthly basis and that his last visit to the facility was on [DATE] and that he reviews all resident records when he comes in. When he comes in, his period of review covers from his last visit to the day he re-enters. S6 Pharmacist states that his review includes MARS, treatment sheets, all orders from previous visit to current visit, and any pertinent labs. He said he reviews every resident in the facility. He said to assure he covers everyone, he uses his roster and compares it to the facility's current roster so he can be sure to capture new admits or readmits, etc. He said he did review resident #5's record and no recommendations were made in [DATE]. He stated he did not recall if there was a December PT/INR on this resident as the facility still had 8 days to perform one so he looked at the previous lab value. He stated he did capture the new orders for a change in Coumadin for resident #5 that was written on [DATE] and did not question the dose increase as it was very common to have frequent and large dosage changes depending on what was going on with the resident. He said when he does a review, he looks for red flags such as a previous PT/INR done prior to change and if the PT/INR was greater than 3.0. He said that some labs are done at MD office or lab office and is not on the chart yet. He again said he could not recall if a December PT/INR was on the chart but he wasn't concerned and it is not unusual to have frequent changes in Coumadin. When asked if he was not concerned with the fact that resident #5 had been stable with her PT/INR results for the last three months on Coumadin 1 mg and 2 mg and now had a new order for Coumadin 4 mg and 5 mg which was double the previous dose ordered, he said that he wasn't concerned as to the fact that people on Coumadin have frequent dose changes. During an interview with S3LPN, she confirmed that the first dose of Coumadin, from the order that was placed on the resident (#5) ' s record on [DATE], was not given until [DATE]. A review of the medical record revealed that the drug regimen review was done on [DATE]. Record review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the [DATE] 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room record dated [DATE] revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on [DATE] at 14:21 with cause of death listed as Coumadin Toxicity.

Based on record review and interview, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 8 sample residents on Coumadin out of a total of 12 sampled residents (resident #5) and for all residents in the facility receiving Coumadin and any potential residents on Coumadin therapy (#6 - #21) and any residents with like first and/or last names (#12, #13). Warfarin (Coumadin) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as Warfarin (Coumadin). For resident #5, the facility failed to: 1. ensure that a Coumadin order for Resident #6 was not transcribed for Resident #5; 2. ensure a faxed order for resident #6 was not documented as a telephone order for resident #5; 3. ensure that orders written on a Telephone Order Form included information that ensured the Telephone Order could be traced back to the original written order; 4. have a quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of Coumadin; 5. ensure that a current PT/INR was drawn and filed on the medical record and reviewed to confirm the need for a Coumadin order adjustment prior to the administration of a new increase in dosage of Coumadin; 6. ensure that residents with like names (first and/or last) were not given another resident's medication; 7. have a quality assurance system in place to daily reconcile new orders for Coumadin by reviewing the new Coumadin order along with the most current PT/INR results to validate the change in dosage of Coumadin; 8. ensure that monthly reconciliation of orders was thorough and accurate by reviewing the new Coumadin order along with the most current PT/INR Lab Results to validate the change in dosage of Coumadin and to identify errors in transcription; 9. ensure that the monthly reconciliation of orders, including review of the MAR, was thorough and accurate and identified errors in transcription. 10. ensure an LPN searched to find the order for an increase in the dose of Coumadin for a resident upon finding new Medication packages of Coumadin with increased doses and no new coumadin order on the chart (#6); 11. ensure LPNs were instructed to alert the DON/Administrator when the pharmacy sent new medication packages of coumadin at an increased dose and no order was on the chart (#6). Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician order [REDACTED]. On 12-20-10, the physician faxed an order to increase the Coumadin dose for resident #6 to Coumadin 4 mg every day 1 by mouth except Monday and Thursday; Coumadin 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's orders [REDACTED].#5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on 12-22-2010 when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the Coumadin to the facility for resident #5. The resident was given the incorrect Coumadin dosage and received a substantial increase in Coumadin. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled physician's orders [REDACTED]. When the resident experienced rectal bleeding, the facility failed to check the Warfarin order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on 1-3-2011 with severe abdominal pain and heavy rectal bleeding. Resident #5 died on [DATE] from Coumadin toxicity. The Immediate Jeopardy continues for all residents in the facility on Coumadin (#6 - #21) and any potential new residents who are on Coumadin therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to Coumadin were completed as ordered and the lab results were verified before Coumadin dosage changes; safeguards for transcription of physician orders [REDACTED]. Findings: Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on 1/7/2011. Prothrombin time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as warfarin (Coumadin). PT/INR test are performed to make sure that the Coumadin is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of resident #5's PT/INR Results Lab Form dated 9/28/10 revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated 10/29/10 revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician order [REDACTED]. A review of Resident #5's PT/INR Lab Results Form dated 11-26-10 revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician order [REDACTED]. Review of the resident's clinical record failed to reveal a PT/INR lab result for December 24, 2010, 4 weeks from 11-26-10. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The Telephone Order Form revealed the order was written for resident #5. An interview was conducted with S3 LPN on 1/19/2011 at 10:00 AM. During this interview, S3 LPN verified that she wrote the Telephone Order for Coumadin dated 12/20/2010 at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new Coumadin order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the 12-20-2010 new Coumadin order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, which had resident #6's name typed on it, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new Coumadin order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the Warfarin order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated 12-20-10 had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new Coumadin order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under 12-20-10 were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on 12-22-10, she initialed that Resident #5 had received Coumadin 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on 12-20-10 and 12-22-10 to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on 12-23-10 Resident #5 received the first dose of Coumadin which was from resident #6's Coumadin order that was written on 12-20-10. S3LPN confirmed that Resident #5 received a total of 4 doses of Coumadin 5mg and a total of 8 doses of Coumadin 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated 12-20-10 and this was verified by S3 LPN. Record review of the Nurses Notes for Resident #5 revealed an entry dated 1-3-10 at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the 1/19/2011 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On 1-3-10 at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room Record dated 1/3/11 revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview was conducted with S1 Interim Administrator on 1-14-11 at 11:35 am. During this interview, S1 Interim Administrator confirmed that a significant medication error was discovered with Resident #5 on 1-5-11 after receiving a call from the primary physician's office confirming the Coumadin dosage for Resident #5. When reviewing Resident #5's clinical record, S1 Interim Administrator stated she was unable to find supporting lab work to warrant the change in Coumadin dosage and after continuing investigation, it was discovered that Resident #5 received an increase in Coumadin that was intended for Resident #6. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on 01/07/11 at 14:21 with cause of death listed as Coumadin Toxicity. S1, Interim Administrator confirmed that there is no policy for faxes received, no policy on transcription of physician orders, and no policy for resident's on high risk drugs. 2. Resident # 6: A review of the clinical record revealed cumulative [DIAGNOSES REDACTED]. A review of the December, 2010 Physician Telephone Orders revealed a new Physician's Telephone Order Form dated 12-20-10 for Coumadin 4 mg po everyday except Monday and Thursday and Coumadin 5 mg po on Monday and Thursday for resident #6. An interview with S4 LPN was conducted on 1-14-11 at 2:25pm. During this interview, the S4 LPN stated that she wrote the new order shortly after she arrived to work on 12-21-10 when she found the resident's 4 mg. and 5 mg. Coumadin medications on the counter but could not find the order for the new medication dosage. S4 LPN stated that she remembered she had to call the primary physician to clarify the change in dosage for the Coumadin for this resident. S4 LPN confirmed that the date she wrote the new order for Coumadin was 12-21-10, and not 12-20-10 as was documented on the Physician's Telephone Order Form. S4LPN stated she must of thought it was the 20th but she did not work the 20th. She said the sticker for the refill date from the pharmacy was the 21st as well. This was verified by the label on the medication packages presented by the facility.

Based on record review and interview, the facility failed to ensure that residents are free of significant medication errors for 1 of 8 sample residents on [MEDICATION NAME] out of a total of 12 sampled residents (resident #5) and for all residents in the facility receiving [MEDICATION NAME] and any potential residents on [MEDICATION NAME] therapy (#6 - #21) and any residents with like first and/or last names (#12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). For resident #5, the facility failed to: 1. ensure that a [MEDICATION NAME] order for Resident #6 was not transcribed for Resident #5; 2. ensure a faxed order for resident #6 was not documented as a telephone order for resident #5; 3. ensure that orders written on a Telephone Order Form included information that ensured the Telephone Order could be traced back to the original written order; 4. have a quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of [MEDICATION NAME]; 5. ensure that a current PT/INR was drawn and filed on the medical record and reviewed to confirm the need for a [MEDICATION NAME] order adjustment prior to the administration of a new increase in dosage of [MEDICATION NAME]; 6. ensure that residents with like names (first and/or last) were not given another resident's medication; 7. have a quality assurance system in place to daily reconcile new orders for [MEDICATION NAME] by reviewing the new [MEDICATION NAME] order along with the most current PT/INR results to validate the change in dosage of [MEDICATION NAME]; 8. ensure that monthly reconciliation of orders was thorough and accurate by reviewing the new [MEDICATION NAME] order along with the most current PT/INR Lab Results to validate the change in dosage of [MEDICATION NAME] and to identify errors in transcription; 9. ensure that the monthly reconciliation of orders, including review of the MAR, was thorough and accurate and identified errors in transcription. 10. ensure an LPN searched to find the order for an increase in the dose of [MEDICATION NAME] for a resident upon finding new Medication packages of [MEDICATION NAME] with increased doses and no new [MEDICATION NAME] order on the chart (#6); 11. ensure LPNs were instructed to alert the DON/Administrator when the pharmacy sent new medication packages of [MEDICATION NAME] at an increased dose and no order was on the chart (#6). Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician order [REDACTED]. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's orders [REDACTED].#5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled physician's orders [REDACTED]. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. Resident #5 died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders [REDACTED]. An onsite visit was conducted on [DATE]. This survey determined that the Immediate Jeopardy situation was removed on [DATE]. The deficient practice continues at an actual harm for resident #5 and a potential for more than minimal harm for residents #6 thru #21. Findings: Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. [MEDICATION NAME] time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as [MEDICATION NAME] ([MEDICATION NAME]). PT/INR test are performed to make sure that the [MEDICATION NAME] is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of resident #5's PT/INR Results Lab Form dated [DATE] revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated [DATE] revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician order [REDACTED]. A review of Resident #5's PT/INR Lab Results Form dated [DATE] revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician order [REDACTED]. Review of the resident's clinical record failed to reveal a PT/INR lab result for [DATE], 4 weeks from [DATE]. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The Telephone Order Form revealed the order was written for resident #5. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the Telephone Order for [MEDICATION NAME] dated [DATE] at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new [MEDICATION NAME] order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new [MEDICATION NAME] order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, which had resident #6's name typed on it, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new [MEDICATION NAME] order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the [MEDICATION NAME] order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated [DATE] had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new [MEDICATION NAME] order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under [DATE] were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on [DATE], she initialed that Resident #5 had received [MEDICATION NAME] 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on [DATE] and [DATE] to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on [DATE] Resident #5 received the first dose of [MEDICATION NAME] which was from resident #6's [MEDICATION NAME] order that was written on [DATE]. S3LPN confirmed that Resident #5 received a total of 4 doses of [MEDICATION NAME] 5mg and a total of 8 doses of [MEDICATION NAME] 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated [DATE] and this was verified by S3 LPN. Record review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the [DATE] 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room Record dated [DATE] revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview was conducted with S1 Interim Administrator on [DATE] at 11:35 am. During this interview, S1 Interim Administrator confirmed that a significant medication error was discovered with Resident #5 on [DATE] after receiving a call from the primary physician's office confirming the [MEDICATION NAME] dosage for Resident #5. When reviewing Resident #5's clinical record, S1 Interim Administrator stated she was unable to find supporting lab work to warrant the change in [MEDICATION NAME] dosage and after continuing investigation, it was discovered that Resident #5 received an increase in [MEDICATION NAME] that was intended for Resident #6. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on [DATE] at 14:21 with cause of death listed as [MEDICATION NAME] Toxicity. S1, Interim Administrator confirmed that there is no policy for faxes received, no policy on transcription of physician orders, and no policy for resident's on high risk drugs. An onsite visit was conducted on [DATE]. This survey determined that the Immediate Jeopardy situation was removed on [DATE]. The deficient practice continues at an actual harm for resident #5 and a potential for more than minimal harm for residents #6 thru #21. 2. Resident # 6: A review of the clinical record revealed cumulative [DIAGNOSES REDACTED]. A review of the December, 2010 Physician Telephone Orders revealed a new Physician's Telephone Order Form dated [DATE] for [MEDICATION NAME] 4 mg po everyday except Monday and Thursday and [MEDICATION NAME] 5 mg po on Monday and Thursday for resident #6. An interview with S4 LPN was conducted on [DATE] at 2:25pm. During this interview, the S4 LPN stated that she wrote the new order shortly after she arrived to work on [DATE] when she found the resident's 4 mg. and 5 mg. [MEDICATION NAME] medications on the counter but could not find the order for the new medication dosage. S4 LPN stated that she remembered she had to call the primary physician to clarify the change in dosage for the [MEDICATION NAME] for this resident. S4 LPN confirmed that the date she wrote the new order for [MEDICATION NAME] was [DATE], and not [DATE] as was documented on the Physician's Telephone Order Form. S4LPN stated she must of thought it was the 20th but she did not work the 20th. She said the sticker for the refill date from the pharmacy was the 21st as well. This was verified by the label on the medication packages presented by the facility.

Based on record review and interview, the facility failed to assure that each resident receives the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for 2 of 8 sample residents (resident #5, resident #6) on [MEDICATION NAME] out of a total of 12 sampled residents and for all residents in the facility on [MEDICATION NAME] therapy (#7 - #21) and any potential new residents admitted that are on [MEDICATION NAME] therapy and any residents with like first and/or last names (#5, #6, #12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). The facility failed to: 1. ensure that a [MEDICATION NAME] order for Resident #6 was not transcribed for Resident #5; 2. ensure a faxed order for resident #6 was not documented as a telephone order for resident #5; 3. ensure that orders written on a Telephone Order Form included information that ensured the Telephone Order could be traced back to the original written order (#5); 4. have a quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of [MEDICATION NAME] (#5); 5. ensure that a current PT/INR was drawn and filed on the medical record and reviewed to confirm the need for a [MEDICATION NAME] order adjustment prior to the administration of a new increase in dosage of [MEDICATION NAME] (#5); 6. ensure that residents with like names (first and/or last) were not given another resident's medication (#5); 7. immediately notify the physician caring for resident #5 at the hospital and notify the family immediately upon discovery of a significant [MEDICATION NAME] medication error which resulted in hospitalization of the resident (#5); 8. have a quality assurance system in place to daily reconcile new orders for [MEDICATION NAME] by reviewing the new [MEDICATION NAME] order along with the most current PT/INR results to validate the change in dosage of [MEDICATION NAME] (#5); 9. ensure that monthly reconciliation of orders was thorough and accurate by reviewing the new [MEDICATION NAME] order along with the most current PT/INR Lab Results to validate the change in dosage of [MEDICATION NAME] and to identify errors in transcription (#5); 10. ensure that the monthly reconciliation of orders, including review of the MAR, was thorough and accurate and identified errors in transcription (#5). 11. ensure an LPN searched to find the order for an increase in the dose of [MEDICATION NAME] for a resident upon finding new Medication packages of [MEDICATION NAME] with increased doses and no new [MEDICATION NAME] order on the chart (#6); 12. ensure LPNs were instructed to alert the DON/Administrator when the pharmacy sent new medication packages of [MEDICATION NAME] at an increased dose and no order was on the chart (#6). Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician order [REDACTED]. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's orders [REDACTED].#5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled physician's orders [REDACTED]. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. On [DATE], the facility discovered the [MEDICATION NAME] error for resident #5 and the resident was in Immediate Jeopardy when the facility failed to immediately consult with the physician caring for the resident at the hospital and inform him of the significant [MEDICATION NAME] error. The Immediate Jeopardy was removed for resident #5 when she died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders [REDACTED]. An onsite visit was conducted on [DATE]. This survey determined that the Immediate Jeopardy situation was removed on [DATE]. The deficient practice continues at an actual harm for resident #5 and a potential for more than minimal harm for residents #6 thru #21. Findings: Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. [MEDICATION NAME] time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as [MEDICATION NAME] ([MEDICATION NAME]). PT/INR test are performed to make sure that the [MEDICATION NAME] is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of resident #5's PT/INR Results Lab Form dated [DATE] revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated [DATE] revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician order [REDACTED]. A review of Resident #5's PT/INR Lab Results Form dated [DATE] revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician order [REDACTED]. Review of the resident's clinical record failed to reveal a PT/INR lab result for [DATE], 4 weeks from [DATE]. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The Telephone Order Form revealed the order was written for resident #5. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the Telephone Order for [MEDICATION NAME] dated [DATE] at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new [MEDICATION NAME] order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new [MEDICATION NAME] order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, which had resident #6's name typed on it, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new [MEDICATION NAME] order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the [MEDICATION NAME] order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated [DATE] had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new [MEDICATION NAME] order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under [DATE] were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on [DATE], she initialed that Resident #5 had received [MEDICATION NAME] 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on [DATE] and [DATE] to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on [DATE] Resident #5 received the first dose of [MEDICATION NAME] which was from resident #6's [MEDICATION NAME] order that was written on [DATE]. S3LPN confirmed that Resident #5 received a total of 4 doses of [MEDICATION NAME] 5mg and a total of 8 doses of [MEDICATION NAME] 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated [DATE] and this was verified by S3 LPN. A review of Resident #5's Drug Regimen Review revealed that the Pharmacist reviewed the clinical record on [DATE] and had no recommendations at this time. A phone interview was conducted on [DATE] at 11:45am with S6 Pharmacist. During this interview, S6 Pharmacist said he comes into the facility on a monthly basis and that his last visit to the facility was on [DATE] and that he reviews all resident records when he comes in. When he comes in, his period of review covers from his last visit to the day he re-enters. S6 Pharmacist states that his review includes MARS, treatment sheets, all orders from previous visit to current visit and any pertinent labs. He said he reviews every resident in the facility. He said to assure he covers everyone, he uses his roster and compares it to the facility's current roster so he can be sure to capture new admits or readmits, etc. He said he did review resident #5's record and no recommendations were made in [DATE]. He stated he did not recall if there was a December PT/INR on this resident as the facility still had 8 days to perform one so he looked at the previous lab value. He stated he did capture the new orders for a change in [MEDICATION NAME] for resident #5 that was written on [DATE] and did not question the dose increase as it was very common to have frequent and large dosage changes depending on what was going on with the resident. He said when he does a review, he looks for red flags such as a previous PT/INR done prior to change and if the PT/INR was greater than 3.0. He said that some labs are done at MD office or lab office and is not on the chart yet. He again said he could not recall if a December PT/INR was on the chart but he wasn't concerned and it is not unusual to have frequent changes in [MEDICATION NAME]. When asked if he was not concerned with the fact that resident #5 had been stable with her PT/INR results for the last three months on [MEDICATION NAME] 1 mg. and 2 mg and now had a new order for [MEDICATION NAME] 4 mg and 5 mg which was double the previous dose ordered, he said he wasn't concerned as to the fact that people on [MEDICATION NAME] have frequent dose changes. Record review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the [DATE] 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room Record dated [DATE] revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview was conducted on [DATE] at 11:35 am with S1, Interim Administrator. S1 Interim Administrator stated that she was informed of Resident #5's [DATE] hospital admit for a suspected GI bleed during the morning meeting that was held on [DATE]. S1, Interim Administrator stated on [DATE], while she was sitting at the Central Desk Nurse's Station, Resident #5's doctor's office called to confirm the current dose of [MEDICATION NAME] being given to Resident #5. She said she then pulled Resident #5's medical record, told her the current dose and hung up the phone. S1, Interim Administrator stated that she noticed that the current [MEDICATION NAME] dose was a new hand written order and that her last PT/INR was done in November, 2010, and was not an abnormal lab. S1, Interim Administrator stated that she did not understand why the dosage of [MEDICATION NAME] had been changed for Resident #5 and she suspected something was suspicious because Resident #5 had been admitted with a GI bleed and had a hand written [MEDICATION NAME] order. S1, Interim Administrator wanted to know what the PT/INR results were to cause a change in the [MEDICATION NAME] dosage, so she called a member of the facility's medical records staff who oversees that labs are ordered and the lab results are filed and asked about Resident #5's PT/INR results that should have been drawn on [DATE]. The member of the facility's medical record staff told S1, Interim Administrator that no labs were drawn on Resident #5. S1, Interim Administrator then asked for a list of residents that had labs drawn from [DATE] though [DATE] for any residents that had a PT/ INR drawn during that time period. S1, Interim Administrator noticed that Resident #6 did have a PT/ INR drawn on [DATE]. S1, Interim Administrator then informed the DON that she felt something was not right with the [MEDICATION NAME] order on Resident #5's medical record. S1, Interim Administrator looked at Resident #6's medical record and noticed the new [MEDICATION NAME] order written on Resident # 6's PT/INR Lab Report Form dated [DATE] was the same [MEDICATION NAME] dose as Resident #5's handwritten order. She then said it was strange that S3, LPN, who never worked on the South Hall and is never assigned to Resident #6 but is assigned to Resident #5, had taken off the order for Resident #6. S1, Interim Administrator then said that when she questioned S3, LPN on [DATE], S3LPN confirmed that she had gotten the order to increase Resident #5's [MEDICATION NAME] from that PT/INR Lab Report Form and then S1, Interim Administrator pointed out that the name on the top of the PT/INR Lab Form was Resident #6's , not Resident #5's. S3, LPN then admitted that she must have only looked at the first name and written the order on the wrong chart. S1, Interim Administrator stated that she attempted to call the attending physician's office on [DATE], but they were closed already. On [DATE], S1, Interim Administrator called again for the attending physician and was told that he was out of the office. S1 Interim Administrator stated she then called the primary physicians wife and asked her to have him call the facility when she heard from him. S1, Interim Administrator stated that the attending physician called her late afternoon on [DATE] and she notified him of the transcription error and what she suspected had happened in regard to Resident #5's [MEDICATION NAME] order. According to S1, Interim Administrator, he thanked her for letting him know. S1, Interim Administrator stated she didn't think of letting the hospital know about the error since she had let the attending physician know about both of his patients at the nursing home. She further stated that she did not even think about calling the hospital because the attending physician was made aware. S1 Interim Administrator also confirmed that the family was not notified of the medication error until [DATE] due to the resident's demise and funeral. S1 Interim Administrator stated she felt prior to this date ([DATE]), it was an inappropriate time to discuss the issue of a medication error involving Resident #5. During the interview with S1, Interim Administrator, when asked if the Pharmacist had been notified of the medication error at this time, S1, Interim Administrator and S2, DON stated that he had not been notified as of [DATE] at 11:45 am. A review of the Pharmacy Policy and Procedure Manuel Subject: Medication Errors and Adverse Reaction procedure reads : The medical director, director of nursing services, and consultant pharmacist must be informed of all medication errors and adverse reactions. S1, Interim Administrator stated that all faxes go to the main fax machine located at the West Desk Nurse's Station and then are brought to the Nurse's Station that the resident belongs to. S1, Interim Administrator confirmed that the facility does not have a specific place to put the orders, but she thinks they put them by the phone, somewhere for nurses to see. S1, Interim Administrator confirmed that there is no policy for faxes received, no policy on transcription of physician orders, and no policy for resident's on high risk drugs. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on [DATE] at 14:21 with cause of death listed as [MEDICATION NAME] Toxicity. During an interview with S2, DON on [DATE] at 9:30 am regarding the name alert stickers that had been placed on the resident's medical records during the survey, she stated "We did not know we had the name alert stickers, but we found them yesterday so we started using them facility wide." An onsite visit was conducted on [DATE]. This survey determined that the Immediate Jeopardy situation was removed on [DATE]. The deficient practice continues at an actual harm for resident #5 and a potential for more than minimal harm for residents #6 thru #21. 2. Resident # 6: A review of the clinical record revealed cumulative [DIAGNOSES REDACTED]. A review of the December, 2010 Physician Telephone Orders revealed a new Physician's Telephone Order Form dated [DATE] for [MEDICATION NAME] 4 mg po everyday except Monday and Thursday and [MEDICATION NAME] 5 mg po on Monday and Thursday for resident #6. An interview with S4 LPN was conducted on [DATE] at 2:25pm. During this interview, the S4 LPN stated that she wrote the new order shortly after she arrived to work on [DATE] when she found the resident's 4 mg. and 5 mg. [MEDICATION NAME] medications on the counter but could not find the order for the new medication dosage. S4 LPN stated that she remembered she had to call the primary physician to clarify the change in dosage for the [MEDICATION NAME] for this resident. S4 LPN confirmed that the date she wrote the new order for [MEDICATION NAME] was [DATE], and not [DATE] as was documented on the Physician's Telephone Order Form. S4LPN stated she must of thought it was the 20th but she did not work the 20th. She said the sticker for the refill date from the pharmacy was the 21st as well. This was verified by the label on the medication packages presented by the facility. S1, Interim Administrator confirmed that there is no policy for faxes received, no policy on transcription of physician orders, and no policy for resident's on high risk drugs.

Based on record review and interview, the facility failed to ensure that residents are free of significant medication errors for 1 of 8 sample residents on [MEDICATION NAME] out of a total of 12 sampled residents (resident #5) and for all residents in the facility receiving [MEDICATION NAME] and any potential residents on [MEDICATION NAME] therapy (#6 - #21) and any residents with like first and/or last names (#12, #13). [MEDICATION NAME] ([MEDICATION NAME]) is an anti-coagulant (blood thinning) drug. PT/INR Lab Tests evaluate the ability of blood to clot properly and monitors the effectiveness of anti-coagulant drugs such as [MEDICATION NAME] ([MEDICATION NAME]). For resident #5, the facility failed to: 1. ensure that a [MEDICATION NAME] order for Resident #6 was not transcribed for Resident #5; 2. ensure a faxed order for resident #6 was not documented as a telephone order for resident #5; 3. ensure that orders written on a Telephone Order Form included information that ensured the Telephone Order could be traced back to the original written order; 4. have a quality assurance check to identify incorrectly transcribed orders before the resident received the wrong dose of [MEDICATION NAME]; 5. ensure that a current PT/INR was drawn and filed on the medical record and reviewed to confirm the need for a [MEDICATION NAME] order adjustment prior to the administration of a new increase in dosage of [MEDICATION NAME]; 6. ensure that residents with like names (first and/or last) were not given another resident's medication; 7. have a quality assurance system in place to daily reconcile new orders for [MEDICATION NAME] by reviewing the new [MEDICATION NAME] order along with the most current PT/INR results to validate the change in dosage of [MEDICATION NAME]; 8. ensure that monthly reconciliation of orders was thorough and accurate by reviewing the new [MEDICATION NAME] order along with the most current PT/INR Lab Results to validate the change in dosage of [MEDICATION NAME] and to identify errors in transcription; 9. ensure that the monthly reconciliation of orders, including review of the MAR, was thorough and accurate and identified errors in transcription. 10. ensure an LPN searched to find the order for an increase in the dose of [MEDICATION NAME] for a resident upon finding new Medication packages of [MEDICATION NAME] with increased doses and no new [MEDICATION NAME] order on the chart (#6); 11. ensure LPNs were instructed to alert the DON/Administrator when the pharmacy sent new medication packages of [MEDICATION NAME] at an increased dose and no order was on the chart (#6). Resident #5 and #6 have the same first name, the same attending physician, and reside on different halls. Resident #5's Physician order [REDACTED]. On [DATE], the physician faxed an order to increase the [MEDICATION NAME] dose for resident #6 to [MEDICATION NAME] 4 mg every day 1 by mouth except Monday and Thursday; [MEDICATION NAME] 5 mg 1 by mouth Monday and Thursday. Resident #5 was placed in Immediate Jeopardy when S3 LPN transcribed the physician's orders [REDACTED].#6 to a Telephone Order Form for resident #5. The nurse failed to write on the Telephone Order Form where the order originated from. The nurse failed to write on the Telephone Order Form that this was an order copied from a PT/INR Lab Result Form faxed to the facility by the physician and not a telephone order. Resident #5 remained in Immediate Jeopardy on [DATE] when S3 LPN faxed the telephone order to the pharmacy for resident #5. The pharmacy filled the order and sent the [MEDICATION NAME] to the facility for resident #5. The resident was given the incorrect [MEDICATION NAME] dosage and received a substantial increase in [MEDICATION NAME]. The facility failed to ensure an order for [REDACTED].#6. The resident remained in Immediate Jeopardy when the facility reconciled physician's orders [REDACTED]. When the resident experienced rectal bleeding, the facility failed to check the [MEDICATION NAME] order and lab results for PT/INR testing. The Immediate Jeopardy was removed for Resident #5 when the resident was transferred to the hospital on [DATE] with severe abdominal pain and heavy rectal bleeding. Resident #5 died on [DATE] from [MEDICATION NAME] toxicity. The Immediate Jeopardy continues for all residents in the facility on [MEDICATION NAME] (#6 - #21) and any potential new residents who are on [MEDICATION NAME] therapy and for residents with like first and/or last names (#12, #13). The Immediate Jeopardy continues as the facility failed to put a system in place to ensure the deficient practices do not occur again including systems to ensure: accurate transcription of orders for the correct resident; labs specific to [MEDICATION NAME] were completed as ordered and the lab results were verified before [MEDICATION NAME] dosage changes; safeguards for transcription of physician orders [REDACTED]. Findings: Resident #5: Record review revealed resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE] and expired on [DATE]. [MEDICATION NAME] time (PT) evaluates the ability of blood to clot properly. International Normalized Ratio (INR) monitors the effectiveness of anti-coagulant (blood thinning) drugs such as [MEDICATION NAME] ([MEDICATION NAME]). PT/INR test are performed to make sure that the [MEDICATION NAME] is producing the desired effect; that it is increasing a resident's clotting time to a therapeutic level without causing excessive bleeding or bruising. A review of resident #5's PT/INR Results Lab Form dated [DATE] revealed PT: 18.4 sec and INR: 2.56. Written on the Form was Dose 2 mg. M and Th; 1 mg all other days. Also written was OK and repeat 4 weeks. A review of Resident #5's PT/INR Results Form dated [DATE] revealed PT: 18.2 and INR: 2.25. Written on the Form was Dose 2 mg. M and Th; 1 mg. all other days. Also written was OK and 4 weeks. A review of Resident #5's Physician order [REDACTED]. A review of Resident #5's PT/INR Lab Results Form dated [DATE] revealed PT: 19.9 and INR: 2.78. Written on the Form was OK and 4 weeks. A review of the November, 2010 Physician order [REDACTED]. Review of the resident's clinical record failed to reveal a PT/INR lab result for [DATE], 4 weeks from [DATE]. Record review failed to reveal a PT/INR lab result for December. Review of Resident #5's clinical record revealed an order written [REDACTED]. The Telephone Order Form revealed the order was written for resident #5. An interview was conducted with S3 LPN on [DATE] at 10:00 AM. During this interview, S3 LPN verified that she wrote the Telephone Order for [MEDICATION NAME] dated [DATE] at 4:30 PM which was in Resident #5's chart. S3,LPN stated she transferred the new [MEDICATION NAME] order for Resident #6 onto Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A PT/INR Lab Results Form which had the [DATE] new [MEDICATION NAME] order written on it by the physician was noted to be for Resident #6 and not Resident #5. When shown this Lab Result Form, which had resident #6's name typed on it, S3 LPN confirmed that it was the Form she obtained the order from. S3 LPN confirmed this by stating that the signature on the lab form was hers and that she did transcribe the order. S3 LPN also verified that the PT/INR Lab Results Form with the new [MEDICATION NAME] order was for Resident #6 and not for Resident #5. S3 LPN stated that when she read the order, she evidently looked at the first name on the Lab Result Form and didn't read the last name. S3 LPN stated that Resident #5 and Resident #6 both had the same first name. She said when she saw the Lab Results Form for resident #6 which had the [MEDICATION NAME] order on it, she read the first name on it and assumed that it was for the resident that she was caring for which was Resident #5. During the interview, S3 LPN stated that once she had the order that was on the PT/INR Lab Results Form for resident #6, she transferred that order to a Physician Telephone Order Form for resident #5. S3 LPN confirmed that the residents name written on the Physician Telephone Order Form was Resident #5. S3LPN stated she then wrote the new order on a plain sheet of white copy paper and faxed the order to resident #5's pharmacy. S3 LPN verified that the Pharmacy order dated [DATE] had Resident #6's name on it but had the name of Resident #5's Pharmacy on the slip. S3 LPN again stated that she can only assume that she just read the first name on the slip but kept reading Resident #5's last name in her mind. During the interview, S3,LPN stated after she performed these actions, she then transferred the new [MEDICATION NAME] order for Resident #6 to Resident #5 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The December MAR indicated [REDACTED]. S3 LPN confirmed that the initials on the MAR under [DATE] were her initial but stated that Resident #5 did not received the medication as the new dosage was not in from the Pharmacy yet. S3 LPN also confirmed that on [DATE], she initialed that Resident #5 had received [MEDICATION NAME] 4mg but in fact she did not receive that dose as the medication was still not in from the Pharmacy. S3 LPN stated that the procedure for the facility in regards for a missed dose of medication is to circle her initials written under the date of the missed dose and to write on the back of the MAR indicated [REDACTED]. S3 LPN stated she should have circled her initials on [DATE] and [DATE] to indicate a missed dose of medication but that she failed to do this. S3 LPN stated she has no idea why she didn't circle these two doses as per protocol. At this time, S3 LPN confirmed that on [DATE] Resident #5 received the first dose of [MEDICATION NAME] which was from resident #6's [MEDICATION NAME] order that was written on [DATE]. S3LPN confirmed that Resident #5 received a total of 4 doses of [MEDICATION NAME] 5mg and a total of 8 doses of [MEDICATION NAME] 4mg by mouth that was intended for Resident #6. A review of the Lab results in the clinical record of Resident #5 failed to find a PT/INR result dated [DATE] and this was verified by S3 LPN. Record review of the Nurses Notes for Resident #5 revealed an entry dated [DATE] at 8 pm: resident has MD appt in am due to rectal bleeding, family notified, family member will attend with resident. The Nurses Note was signed by S3 LPN. During the [DATE] 10:00 A.M. interview, S3 LPN verified that this entry was written by her and was actually a late entry from an incident that occurred earlier in the shift. S3 LPN stated that she was notified by the CNA on duty that Resident #5 was having some rectal bleeding and that she called the Primary Physician to notify him of the issue at around 3 or 4 pm that day. S3 LPN stated she was given an appointment for Resident #5 for the next morning and was told if the bleeding became more severe prior to the appointment time to send the resident to the emergency room . S3 LPN stated she did not write in her nurses notes until 8 pm and should have written late entry to show that this was something that occurred at a different time. On [DATE] at 9pm, an entry in Resident #5's Nurses Notes revealed resident complaining of severe abdominal pain; large amount of blood noted .....MD notified ...fly (family) request to send to hospital ambulance called ... ....VS ...9:19pm transferred to hospital. Record Review of the hospital's emergency room Record dated [DATE] revealed Resident #5 was admitted with a [DIAGNOSES REDACTED]. An interview was conducted with S1 Interim Administrator on [DATE] at 11:35 am. During this interview, S1 Interim Administrator confirmed that a significant medication error was discovered with Resident #5 on [DATE] after receiving a call from the primary physician's office confirming the [MEDICATION NAME] dosage for Resident #5. When reviewing Resident #5's clinical record, S1 Interim Administrator stated she was unable to find supporting lab work to warrant the change in [MEDICATION NAME] dosage and after continuing investigation, it was discovered that Resident #5 received an increase in [MEDICATION NAME] that was intended for Resident #6. Record Review of the Louisiana Organ Procurement Agency's Notification of Death Form, revealed Resident # 5 expired on [DATE] at 14:21 with cause of death listed as [MEDICATION NAME] Toxicity. S1, Interim Administrator confirmed that there is no policy for faxes received, no policy on transcription of physician orders, and no policy for resident's on high risk drugs. 2. Resident # 6: A review of the clinical record revealed cumulative [DIAGNOSES REDACTED]. A review of the December, 2010 Physician Telephone Orders revealed a new Physician's Telephone Order Form dated [DATE] for [MEDICATION NAME] 4 mg po everyday except Monday and Thursday and [MEDICATION NAME] 5 mg po on Monday and Thursday for resident #6. An interview with S4 LPN was conducted on [DATE] at 2:25pm. During this interview, the S4 LPN stated that she wrote the new order shortly after she arrived to work on [DATE] when she found the resident's 4 mg. and 5 mg. [MEDICATION NAME] medications on the counter but could not find the order for the new medication dosage. S4 LPN stated that she remembered she had to call the primary physician to clarify the change in dosage for the [MEDICATION NAME] for this resident. S4 LPN confirmed that the date she wrote the new order for [MEDICATION NAME] was [DATE], and not [DATE] as was documented on the Physician's Telephone Order Form. S4LPN stated she must of thought it was the 20th but she did not work the 20th. She said the sticker for the refill date from the pharmacy was the 21st as well. This was verified by the label on the medication packages presented by the facility.