Health inspection·June 4, 2025

REGULATION VIOLATION(S) F760 (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) The facility failed to ensure Resident 1 was free from significant medication error when Resident 1 received MS Contin ER (Morphine Sulphate extended release), a narcotic medication, on 8/6/2021, which was not ordered by the Physician. Resident 1 had an adverse reaction to the medication and required hospitalization in the acute care facility for ten days. Resident 1 was admitted to the intensive care unit (ICU), where she received an intravenous (given into the vein) medication to reverse the effects of the narcotic medication, and an intravenous medication to maintain her blood pressure. Findings: Resident 1 was admitted to the Skilled Nursing Facility on 5/13/21, with diagnoses including acute and chronic respiratory failure, chronic heart failure, and seizure disorder. Resident 1's Minimum Data Set (MDS), dated 5/20/21, indicated Resident 1 had clear speech, was understood when she spoke, and was able to understand when spoken to. Resident 1's Brief Interview for Mental Status (BIMS) indicated a score of 3/15. (The MDS is an assessment tool to determine the functional status, mood, and medical conditions of Nursing Home residents. The BIMS is an assessment tool to determine a resident's attention, orientation, and ability to recall information. A score of 3 out of 15 possible correct answers to questions indicates severe cognitive impairment). During an interview on 8/12/2021 at 10 a.m., the Director of Nurses (DON) stated Resident 1 had tested positive for Covid-19 virus and was in quarantine in the Red Zone of the facility on 8/6/2021. The DON stated Resident 1 received a narcotic medication ordered for Resident 1's roommate, Resident 2. The DON stated the narcotic was administered in the morning, but Licensed Nurse A did not realize the error until early afternoon when Resident 1 was confused and lethargic. During an interview on 8/19/2021 at 3 p.m., Licensed Nurse A stated she had not worked with the residents before and had not worked with any resident in a Red Zone of the facility before. Licensed Nurse A stated she did not check Resident 1's identification armband and did not check Resident 1's roommate's identification armband before administering the narcotic to Resident 1. Licensed Nurse A stated she called out the name of Resident 1's roommate (Resident 2) and Resident 1 responded. Licensed Nurse A stated Resident 1's roommate did not respond when Resident 1's roommate's name was called. Licensed Nurse A stated she did not remember if the residents' pictures were available in the Medication Administration Records (MAR). Licensed Nurse A stated she notified the Assistant Director of Nurses (ADON) when she realized she gave Resident 1 a narcotic, MS Contin ER 30 mg, which was ordered for Resident 1's roommate (Resident 2). (MS Contin ER is a brand of long-acting morphine, intended for management of severe pain. The side effects include respiratory depression and low blood pressure). During an interview on 8/18/2021 at 4 p.m., the DON stated Licensed Nurse A had recently received her Licensed Vocational Nurse license (LVN) but had worked as a Certified Nurse Assistant at the facility while studying to become an LVN. The DON stated the MARs had photos of the residents, and all residents had armbands for identification, but some residents removed their armbands. The DON stated Resident 1 was not able to identify her own medication, but Resident 1's roommate was able to identify her own medication. The DON stated Licensed Nurse A notified the ADON, who notified the DON at 1:45 p.m., that a narcotic had been given to the incorrect resident. The DON stated the expectation was the Licensed Nurse would give the correct medicine at the correct time to the correct resident by the correct route. During a review of documents on 8/12/2021, the census sheet for 8/6/2021, indicated Licensed Nurse A was the Licensed Nurse for Side 1, which had three residents in quarantine, in the Red Zone, due to testing positive for Covid-19 virus and 30 residents in the Yellow Zone, who were negative for the virus. During a review of records on 8/12/2021, Licensed Nurse A's notes indicated a set of vital signs (Blood pressure, pulse, temperature) on Resident 1 at 12:30 p.m., due to increased lethargy and again at 1 p.m. Both sets of vital signs and oxygenation levels were within normal range. The note indicated the Physician was notified and gave the order to send Resident 1 to the Emergency Department for further observation. During a review of medical records on 8/12/2021, Resident 1's MAR (Medication Administration Record) did not indicate an order for MS Contin ER 30 mg. During a review of medical records on 8/12/2021, the MAR for Resident 1's roommate, Resident 2, indicated MS Contin ER 30 mg was administered by Licensed Nurse A at 8 a.m. on 8/6/2021. During a review of documents on 8/12/2021, the document titled, "Corrective Action Memo," dated 8/8/2021, by the DON, about Licensed Nurse A, indicated the MS Contin was given out of the correct time parameters for medication administration. The document indicated Licensed Nurse A admitted the medication was removed from inventory at 10 a.m. The MAR for Resident 1's roommate indicated the correct time for administration of MS Contin ER 30 mg was 8 a.m. During a review of Resident 1's medical records from the acute care hospital, on 10/14/21, the Emergency Department Report, dated 8/6/21 at 2:23 p.m., indicated, "...patient was accidentally given a dose of Morphine 30 mg this morning at 1000 (10 a.m.). Per EMS, patient was accidentally administered her roommate's dose of long-acting morphine 30 mg. ...Patient was provided with Narcan (medicine that rapidly reverses an opioid overdose) 0.4 mg (milligram) en route prior to arrival." Resident 1 was, "somewhat somnolent and confused but was able to communicate with the medical staff," when she arrived at the Emergency Department. Resident 1 became increasingly difficult to arouse and required an intravenous medication, Narcan, to counteract the effects of the narcotic medication, and an intravenous medication, Levophed (medication used to treat life-threatening low blood pressure (hypotension)), to maintain her blood pressure. Resident 1 was admitted to the Intensive Care Unit (ICU) at 5:44 p.m. An acute care record titled, "History and Physical," dated 8/7/21, revealed Resident 1, "had an iatrogenic (Adverse physical condition induced in a patient by effects of treatment by a Physician) complication from the wrong medication administration re: MS Contin 30 mg. She developed hypotension (low blood pressure) and obtundation (reduced level of alertness or consciousness) ..." During a review of facility policies on 8/12/21, the policy titled, "Medication Administration," not dated, indicated the Licensed Nurses had to verify the resident's identity before administering medications and also maintain a resident's right to the correct medication, at the right time, in the right amount, and by the right route. Therefore, the facility failed to ensure Resident 1 was free from a significant medication error when Resident 1 was administered MS Contin ER (Morphine Sulphate extended release), a narcotic medication, on 8/6/2021, which was not ordered by the Physician for her, causing Resident 1 to have an adverse reaction to the medication, requiring hospitalization in the acute care facility for ten days. The violation of the regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.