Other·May 29, 2024

F760 483.45(f)(2) Based on interview, record review and policy review, the facility failed to ensure that registry Licensed Vocational Nurse (LVN) 1 (a nurse from a registry staffing agency is not a permanent employee of the facility), was oriented to the facility's medication administration system, was accompanied by a Charge Nurse for at least three days to ensure that the facility's established medication administration procedures had been learned, and that LVN 1 followed the "five rights" of identifying a resident before administering medication (right resident, right medication, right dose, right time and right route (as in by mouth, injection or intravenously), for one of two residents (Resident 1) sampled for medication errors and LNV 1 gave Resident 1 cardiac (heart medications) and blood pressure medications that were prescribed for Resident 2. This medication error had a significant negative impact on Resident 1's physical condition and resulted in a drop Resident 1's blood pressure to 94/56 (normal range is considered 120/80) and heart rate to 40 (normal range is considered 80), which required an emergency transfer to the acute care hospital and subsequent admission to the hospital's Intensive Care Unit (ICU, for critically ill patients), where he required treatment for two days to get his blood pressure stabilized. Findings: The facility's policy titled, "Administering Medications" revised April 2019, was provided by the Director of Nursing (DON) and reviewed. The policy indicated; "9. Individual administering medication verifies resident identification before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band, b. Check photograph attached to the medical record, c. Verify with another personnel." "10. The individual administering medications checks the label THREE (3) times to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication." "29. New personnel authorized to administer medication are not permitted to prepare or administer medication until they have been oriented to the medication administration system used by the facility." "30. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned." The facility's policy titled, "Adverse Consequences and Medication Errors" revised February 2023, was provided by the DON and reviewed. The policy indicated; "Adverse Consequence refers to unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status." "Medication Error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer's specifications, or accepted professional standards and principles of the professional(s) providing services." "A significant medication related error is defined as, b. Requiring hospitalization or extending a hospitalization. d. Requiring treatment with a prescription medication. f. Life threatening." Resident 1's Admission Record was reviewed and indicated that Resident 1 was admitted to the facility on 11/23/23 with a diagnoses that included heart disease (damaged heart vessels), high blood pressure, atrial fibrillation (an irregular heart beat), diabetes (high blood sugar), benign prostatic hypertrophy (BPH- an enlarged prostate gland), obesity, chronic obstructive pulmonary disease (COPD-lung damage that makes breathing difficult), weakness, and dependent on oxygen use (air delivered through a tube in the nose). A review of Resident 1's Admission Minimum Data Set (MDS, a standardized assessment tool), dated 12/12/23, reflected that Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that he had no cognitive (memory and understanding) problems. On 3/14/24 at 8 am, the facility's Administrator (Admin) reported by email to the California Department of Public Health (CDPH), that Resident 1 was mistakenly given his roommate's medication on the morning of 3/13/24, and that Resident 1 had an adverse reaction to those medications and was currently admitted into the ICU at the local acute care hospital. On 3/14/24 at 10 am, an interview and concurrent record review of Resident 1 and Resident 2's Medication Administration Records (MARs) for the month of March 2024 and Physician's Orders for March 2024, was conducted with the DON. The DON confirmed that Resident 1 was currently in the ICU at the local acute care hospital (H)1. The DON indicated that on 3/13/24 at around 9 am, LN 1 had given Resident 1 Resident 2's medications and LN 1 reported this to the DON. DON indicated that LN 1 had not followed the facility's policy on identifying Resident 1 when LN 1 asked Resident 1 if his name was [Resident 2's name]. At that time, Resident 1 indicated that was his name. DON indicated that LN 1 had not used the facility's method for identifying a resident prior to giving medications and should have at a minimum, checked Resident 1's armband, or asked another nurse for help in verifying who Resident 1 was. The DON indicated that the MAR showed Resident 1 as being in the "B" bed and Resident 2 in the "A" bed, which was incorrect, and that Resident 1 was in the A bed and Resident 2 was in the B bed. DON indicated this was a data entry error on the facility's part. DON added that instead of administering medications according to the bed a resident was in- LN 1 should have further verified who the resident was to ensure she was administering the medications to the right resident. The DON indicated that LN 1 gave Resident 1 the following 7 heart and blood pressure medications that were prescribed for Resident 2; Diltiazem (a medication to lower blood pressure called Calcium Channel blockers which block the movement of calcium and is more effective with large vessel stiffness), 360 mg (mg is a unit of measuring weight of medication), XR (Extended release, medication continues to be released slowly into the system for 12-24 hours), Eliquis (a blood thinner to prevent blood clots) 5 mg, Coreg (a medication to lower blood pressure and heart rate called Beta blockers which block adrenaline so the heart beats slower) 25 mg, Isosorbide Mononitrate (used to prevent chest pain) 30 mg, Lisinopril (a medication to lower blood pressure), 40 mg, Clonidine (a sedative and blood pressure lowering medication) 0.1 mg, and Lasix (a water pill that lowers blood pressure) 40 mg. Resident 1's MAR indicated that he had only 2 heart and blood pressure medications prescribed; Metoprolol ER 25 mg (an extended release Beta blocker) and Losartan 50 mg (a blood pressure lowering medication). The DON indicated that around 10:20 am, Resident 1 was "lethargic" (sluggish) and that he had stated, "I'm tired and want to lay down." At that point 911 was called and Resident 1 left shortly thereafter by ambulance. The DON confirmed that according to the facility's Adverse Consequences and Medication Errors policy, LN 1 made a "significant medication error." On 3/14/24 at 4:16 pm, an interview was conducted with LVN 1. LVN 1 confirmed that during the morning medication pass on 3/13/24, she had given Resident 1 the above medications which were prescribed for Resident 2. LVN 1 stated, "I went in and asked A bed if his name was [Resident 2's name], he said yes and took the medication. He was so with it, I thought he knew his name." LVN 1 indicated that when she went on to give bed B (Resident 2) his medication she asked if his name was (Resident 1's name) and he said, "No, that's the other guy." LVN 1 confirmed that she had not checked armbands or asked another nurse who was familiar with the residents to help her verify who Resident 1 and 2 were. LVN 1 stated, "I just felt like oh my God, I just gave the wrong meds [to Resident 1], I told both residents and the DON and called the family of [Resident 1] and the doctor." LVN 1 stated, "I could not see the pictures on the MAR because they are too small and poor quality, and the residents were in the wrong beds. I am new here. I should have asked someone else to help me verify." LVN 1 indicated that within one hour Resident 1's blood pressure had dropped to 95/26 and his heart rate was 40, "so we called 911." LVN 1 stated that her training by the facility consisted of, "We get a packet of things. They give it to us and we review it. That's all. The Medication Administration policies are in the packet, but I did not have time to review them. All I got was oriented to the unit. The rest was in the packet. They gave it to me on the first day I was there and I started working immediately, with no training." On 3/26/24, Resident 1's medical records were obtained from a Registered Nurse at H1 and reviewed. The "ED [Emergency Department] Physicians Notes" dated 3/13/23 at 1:29 pm, dictated by the ED physician (MD) 1, indicated that Resident 1 had been brought into H1 by ambulance from the facility after having low blood pressure and heart rate after taking his roommates heart and blood pressure medications. Blood pressure in the ED was 94/52 and Resident 1's heart rate was 47. Resident 1 was given intravenous (IV, directly given to the blood stream by way of a small plastic tube); Atropine (to increase heart rate), Glucagon (for low blood sugar), Calcium Gluconate (to block calcium and prevent a heart attack), and Levophed (used to treat low blood pressure and requires constant monitoring and titration (adjustments)). MD 1 documented, "Failure to initiate these interventions could result in multi-organ failure, serious morbidity (medical problems), and death, requiring my highest level of preparedness to intervene emergently." MD 1 requested Resident 1 be evaluated by a Critical Care physician (CCP) 2, (a doctor who generally works in the ICU and takes care of critically ill patients). The H1 "Admission History and Physical [H&P]" dated 3/13/24 at 1:54 pm, dictated by the CCP 2 was reviewed. The "final report" indicated that Resident 1's diagnoses were Shock (a life-threatening condition due to lack of blood flow and low blood pressure), Bradycardia (low heart rate), and Calcium Channel Blocker overdose (profound lack of blood flow to vital organs). CCP 2 admitted Resident 1 to the ICU for close monitoring by critical care nurses for the administration of IV Levophed and added IV Dopamine (treats symptoms of shock by improving blood flow). The H1 "Discharge Summary" dated 3/15/24 at 9:11 am, dictated by CCP 2 was reviewed. The "Hospital Course" indicated that Poison Control had been contacted regarding Resident 1's Calcium Channel Blocker toxicity and overdose. CCP 2 indicated that the continuous IV Levophed was discontinued on 3/14/24, after 24 hours and Resident 1's blood pressure and heart rate began to stabilize. CCP 2's expectation was that the continuous IV Dopamine could also be titrated (lowered), "the anticipation was that the dose medication [wrong medication that Resident 1 was given at the facility], would be cleared from his system in 24 hours." Once the continuous IV Dopamine dose was lowered, Resident 1's blood pressure once again dropped and the continuous IV Dopamine medication had to be resumed for another day. On 3/15/24, Resident 1 was discharged back to the facility with a normal blood pressure and heart rate. On 4/3/24 at 10 am, an interview was conducted with Resident 1 in his room. Resident 1 stated, "Yes. She [LVN 1], gave me the wrong medicine. It was the medications for my roommate. It happened and she said she made a mistake. After that my blood pressure went down and I was not feeling well at all. So because of that they took me to the hospital and I had to spend a few days in the Intensive Care." Resident 1 stated, "Usually, I would look at my pills and ask them if I thought something wasn't right. But this time I took her word for it and didn't even think of it. It was too late by the time we figured it out. She was new and didn't know me. I guess I didn't know her either." Therefore, this failure to follow procedures to identify residents prior to administering medications had a direct affect on the health, safety and welfare of the residents.