Health inspection·March 19, 2021

F760 §483.45(f)(2) Residents are free of any significant medication errors. On 10/20/2020, an unannounced visit was conducted at the facility to investigate a complaint regarding Quality of Care/Treatment/Resident Medications Not Given According to Physician Instructions. The facility failed to ensure Resident 1 was free from significant medication errors when a student nurse, without the supervision of the instructor, administered Resident 2's ten (10) medications to Resident 1. This failure resulted in Resident 1 experiencing lethargy (deep unresponsiveness), dizziness, and hypotension (low blood pressure), had to be admitted to an acute care hospital with transfer to the intensive care unit (ICU), and a stay in the hospital for seven (7) days for hypotension due to the accidental administration of three medications used to treat high blood pressure: amlodipine, atenolol, and lisinopril while she had low blood pressure diagnosis. Resident 1 was admitted to the facility on 6/14/2018 with diagnoses including hypotension, pancreas transplant status, kidney transplant status, diabetes (a disease in which the blood sugar levels are too high), asthma (a condition in which the airways narrow and swell, and may produce extra mucus, which can make breathing difficult, and cause shortness of breath), heart failure (occurs when the heart muscle does not pump blood as well as it should), end stage renal disease (the kidneys are no longer able to work as they should to meet the body's needs), and dependence on renal dialysis (the blood is put through a filter outside the body, cleaned, and then returned to the body). Review of the facility's Medication Regimen Report of Incident, dated 9/17/19, indicated on 9/17/19 at 8:50 a.m., a student nurse did not check the name outside of Resident 1's room, did not identify Resident 1, and administered to Resident 1 the medications that did not belong to Resident 1. Review of the student nurse's Incident Report Summary indicated on 9/17/19 at around 8:30 a.m. to 9 a.m. after dispensing medications for Resident 2 along with two other classmates and her instructor, the student nurse went ahead to Resident 1's room, and gave Resident 1 the medications for Resident 2. Resident 1 took all the medications that the student nurse gave her except the nose sprays. Resident 1 refused the nose sprays. Review of the instructor's Written Statement indicated on 9/17/19 at around 8:30 a.m. after preparing all medications for Resident ,2 which were at least three blood pressure medications, the student nurse left to go to the resident room to administer the medications without the instructor's supervision. About 10 minutes later, the student nurse told her that she accidentally gave the medications for Resident 2 to Resident 1. During an interview with the director of nursing (DON) on 10/26/2020 at 1:20 p.m., she stated the student nurse administered 10 wrong medications to Resident 1, and the 10 medications belonged to Resident 2. Review of the facility's Medication Error report and Resident 2's 9/2019 Medication Administration Record (MAR) indicated the 10 medications were amlodipine (used to treat high blood pressure) 10 milligrams (mg, a metric unit of mass), atenolol (used to treat high blood pressure) 100 mg, lisinopril (used to treat high blood pressure) 20 mg, bupropion (used to treat depression) 300 mg, docusate sodium (used to treat occasional constipation) 250 mg, lamotrigine (used to prevent and control seizures) 50 mg, vitamin D (a nutrient that is needed for health and to maintain strong bones) 2000 international units (IU), gabapentin (used to prevent and control seizures and to relieve nerve pain) 300 mg, levetiracetam (used to treat seizures) 500 mg, and senna (used to treat constipation) 8.6 mg. Resident 1 was given Resident 2's 10 medications including three medications for high blood pressure. Resident 1 had low blood pressure diagnosis prior to the medication errors. Review of Resident 1's Progress Notes, dated 9/17/19 at 1:56 p.m., indicated Resident 1's blood pressure was 99/58 at 10 a.m., 82/52 at 11 a.m., 99/66 at 11:30 a.m., 83/45 at 11:45 a.m., and around 12 p.m. Resident 1's blood pressure dropped to 77/41. Review of Resident 1's Change of Condition (COC) 911 Transfer, dated 9/17/19, indicated she was sent to the hospital via 911 for low blood pressure, dizziness, and right abdominal quadrant pain. During an interview with Resident 1 on 10/26/2020 at 12:40 p.m., she stated last year a student nurse gave her eight or nine wrong medications and it made her dizzy, she had nausea, and she had to stay in the hospital for more than five (5) days. Review of the first hospital's Emergency Department (ED) Provider Notes, dated 9/17/19, indicated Resident 1 presented with hypotension. Her systolic blood pressure (SBP, indicates how much pressure the blood is exerting against the artery wall when the heart beats) was in the 80s. "Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Shock." Resident 1 was given intravenous fluid (IVF, liquids are given straight into a vein through a drip) and started on Dopamin (blood pressure support, it can treat symptoms of shock by improving blood flow) and Levophed (used to treat life-threatening low blood pressure). Review of the first hospital's Discharge Summary, dated 9/18/19, indicated Resident 1 was transferred to the second hospital's ICU with critical condition. Review of the second hospital's ICU Admission History and Physical, dated 9/19/19, indicated Resident 1 presented with low blood pressure and lethargy. Review of the second hospital's Discharge Summary, dated 9/25/19, indicated the principal diagnosis for Resident 1's hospital stay was "Hypotension due to inadvertent (accidental) administration of amlodipine, atenolol, and lisinopril at the skilled nursing facility." Review of the agreement between the facility known as Clinical Site and the nursing school, "Clinical Educational Agreement", effective as of 3/1/17, indicated "Clinical Site shall retain ultimate responsibility for patient care and services." In violation of the above cited standards, the facility failed to ensure Resident 1 was free from significant medication errors when a student nurse without the supervision of the instructor administered Resident 2's ten (10) medications to Resident 1. This failure resulted in Resident 1 experiencing lethargy, dizziness, and hypotension, had to be admitted to an acute care hospital with transfer to the ICU, and a stay in the hospital for 7 days for hypotension due to the accidental administration of three medications that used to treat high blood pressure: amlodipine, atenolol, and lisinopril while she had low blood pressure diagnosis. This violation had a direct of immediate relationship to the health, safety, or security of patients or residents.