Other·July 8, 2021

F760 The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. On 5/25/2021, during a recertification survey, medication pass observation was conducted. The facility failed to ensure its medication error rate was less than five percent (5%) and failed to ensure residents' medication regimen was free from significant medication errors for Residents 10, 11, and 269 when: 1. On 5/25/2021, during the medication pass observation for Resident 10, eight medication errors were observed of a total of 30 opportunities for error (a total of 30 medications were observed administered or missed [omitted]. Eight medications were not given within one hour from the scheduled 9 a.m. time (considered medication error), and two medications were omitted (Gabapentin [Neurontin] medication to treat nerve pain and Basaglar KwikPen Pen Injector [Insulin pen to control blood sugar]) for a total of 10 medication errors. Resulting in an overall medication error rate of 33.33%. 2. On 5/25/2021, at 9:00 a.m., during Resident 11’s medication pass, the antibiotic Levofloxacin (was not available and it was not clear if the medication had been discontinued) was not given or available and Celebrex was not given as ordered. 3. On 5/25/2021, at 9:00 a.m., during Resident 269’s medication pass, the medication nurse mixed seven medication and since the resident refused, the mixed medications were wasted. Resident 269 did not get the ordered water pill (Furosemide), the medications for blood pressure (Lisinopril and Carvedilol), the medication to prevent clots (Eliquis), the medication to prevent constipation (Sennosides) and Tums for upset stomach). As a result, Residents 10, 11, and 269, were placed at risk of complications including not maintaining therapeutic range levels (the amount of drug levels in the blood in which a drug has the desired effects upon the body) and had the potential to result in Resident 10 experiencing increase in anxiety, depression, uncontrolled blood pressure and elevated blood sugar, and heart attack, or death. Resident 11 was placed at risk of pain and Resident 269 was placed at risk of cardio-vascular and gastric complications. 1. A review of Resident 10’s Admission Record indicated the facility originally admitted the resident on 4/2/2013 and a readmission dated on 2/18/2021, with diagnoses including, heart failure, hypertension (a condition in which the force of the blood against the artery walls is too high), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose], depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), muscle weakness, and dysphagia (difficulty swallowing). On 5/25/2021, at 11:06 a.m., a Medication Pass (MedPass) observation of Licensed Vocational Nurse 3 (LVN 3) at the East Nursing Station was initiated. LVN 3 was preparing and administering the following medications for Resident 10 orally (by mouth): 1. Aspirin low dose enteric coated 81 mg (milligrams - unit of measure) one tablet (for prevention of heart attack). 2. Digoxin 0.125 mg one tablet (for irregular heartbeat). 3. Metoprolol Succinate ER 50 mg one tablet (white round tablet with drug imprint 565 [pill imprint code is used to uniquely identify all solid oral dosage forms such as tablets, capsules, and pills]) for hypertension. 4. Multiple Vitamin One Daily one tablet (red tablet) as supplement. 5. Vitamin C 500 mg one tablet as supplement. 6. Zinc Sulfate 220 mg one tablet as supplement. 7. Sertraline (Zoloft) 50 mg one tablet for depression (a common and serious medical illness that negatively affects how the person feels, the way they think and how they act). 8. Famotidine (Pepcid) 20 mg one tablet for GERD (gastroesophageal reflux disease - a digestive disorder, occurs when stomach acid flows back into the tube [esophagus] connecting the mouth and stomach). On 5/25/2021, at 11:18 a.m., during interview and concurrent review of the Medication Administration Record (MAR) for the medications above listed and LVN 3 stated Resident 10 was administered eight medications, which was all were scheduled 9:00 a.m. (morning medications for 5/25/2021). A review of Resident 10's Medication Administration Record (MAR) for 5/2021, included the following prescribed orders: a. Ordered start date 2/19/2021 - Aspirin 81 one time a day by mouth for. Take with food, scheduled administration time 9:00 a.m. However, Aspirin 81 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. and not observed administered with food as ordered. b. Ordered start date 3/28/2021 - Digoxin 0.125 mg one time a day by mouth for atrial fibrillation (irregular heartbeat) related to heart failure. Hold if apical pulse (pulse taken on the left side of the chest over the heart) is less than 60 heartbeats per minute, scheduled administration time 9:00 a.m. However, Digoxin 0.125 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. c. Ordered start date 2/19/2021 - Metoprolol-Hydrochlorothiazide (combined antihypertensive medications metoprolol and hydrochlorothiazide [diuretic, water pill]) ER (Extended Release) 24 Hour 50 mg/12.5 mg one tablet by mouth one time a day, scheduled administration time 9:00 a.m. Metoprolol Succinate 50 mg ER without Hydrochlorothiazide 12.5 mg (wrong medication) was administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. d. Ordered start date 2/19/2021- multi-vitamin with minerals one tablet by mouth one time a day for supplement, scheduled administration time 9:00 a.m. Multivitamin without minerals (wrong medication) was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. e. Ordered start date 2/28/2021 - Vitamin C 500 mg one tablet by mouth in the morning for supplement, scheduled administration time 9:00 a.m. Vitamin C 500 mg was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. f. Ordered start date 2/28/2021 - Zinc Sulfate 220 mg one tablet by mouth in the morning for supplement, scheduled administration time 9:00 a.m. Zinc Sulfate 220 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. g. Ordered start date 2/19/2021 - Sertraline (Zoloft) 50 mg one tablet by mouth one time a day for depression manifested by verbalization of sadness, scheduled administration time 9:00 a.m. Sertraline 50 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. h. Ordered start date 2/19/2021 - Famotidine (Pepcid) 20 mg one tablet by mouth two times a day for GERD, scheduled administration times 9:00 a.m. and 9 p.m. However, Famotidine 20 mg medication was observed administered on 5/25/2021, at 11:06 a.m., two hours after scheduled administration time of 9 a.m. i. Ordered start date 2/19/2021 - Gabapentin (Neurontin) 600 mg one tablet by mouth three times a day for Neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) scheduled administration time 9:00 a.m., 1:00 p.m., and 5:00 p.m. Gabapentin 600 mg was not observed administered during morning medication pass observation to Resident 10 on 5/25/2021, for the 9 a.m. administration time. j. Ordered start date 5/14/2021 - Basaglar KwikPen Pen Injector 100 units per ml, Inject 40 units subcutaneously (just under the skin) two times a day for diabetes. Hold if blood sugar less than 100 mg per deciliters (mg/Dl). Rotate site, scheduled administration times 9:00 a.m. and 5:00 p.m. Basaglar Kwikpen Pen Injector 40 units was not observed administered during morning medication pass observation to Resident 10 on 5/25/2021, for the 9 a.m. administration time. On 5/25/2021, at 11:30 a.m., during an interview, LVN 3 stated, the eight medications (Aspirin 81 mg, Digoxin 0.125 mg, Metoprolol Succinate ER 50 mg [imprint on tablet 565, white round tablet], Multiple Vitamin One Daily, one tablet [red tablet], Vitamin C 500 mg, Zinc Sulfate 220 mg, Sertraline (Zoloft) 50 mg, and Famotidine (Pepcid) 20 mg) administered to Resident 10 starting at 11:06 a.m. on 5/25/2021, were the resident's morning medications scheduled for 9 a.m. administration. LVN 3 stated, he was late passing medications to Resident 10, and he had five more residents' rooms to go to complete the 9 a.m. scheduled medication administrations. On 5/26/2021, at 2:29 p.m., during an interview with LVN 3 and concurrent MAR review for Resident 10's 9 a.m. scheduled medications, there were no licensed staff initials (indicating the medication administration) in the boxes for Resident 10's Basaglar Kwikpen or Gabapentin 600 mg tablet. LVN 3 stated Resident 10's Gabapentin was unavailable for administration on 5/25/2021 and again on 5/26/2021. LVN 3 confirmed he had not administered resident's Basaglar Kwikpen injection. On 5/26/2021 at 12:17 p.m., during an interview, DON stated the facility's licensed nurses were supposed to pass medication to the residents within one hour before or within one hour after the scheduled time for medication administration. DON stated medication scheduled for administration to a resident at 9 a.m., the nurse may pass medications starting at 8 a.m. until 10 a.m. 2. During a concurrent observation on 5/25/2021, at 9:21 a.m., with Licensed Vocational Nurse (LVN 6), at the West Nursing Station Medication Cart, LVN 6 prepared and administered seven morning medications on 5/25/201, scheduled for 9:00 a.m. administration time to Resident 11 including: i. Vitamin C (supplement) 500 milligrams (mg- unit of measure), one tablet ii. Folic Acid (medication used to treat low blood cells) 1 mg - one tablet iii. Furosemide (used to reduce extra fluid in the body (edema) caused by conditions such as heart failure) 20 mg, one-half tablet (10 mg) iv.. Magnesium Oxide (supplement) 400 mg, two tablets (800 mg) v. Bupropion hydrochloride (HCL) sustained release (SR) (medication used to treat depression) 150 mg, one tablet vi. Zinc Sulfate (supplement) 220 mg, one tablet vii. Gabapentin (medication to treat nerve pain and seizures [sudden episodes of uncontrollable muscle tone or movements that includes stiffness, twitching or limpness]) 300 mg, three capsules (900 mg). During an interview with LVN 6, on 5/25/2021, at 9:38 a.m., LVN 6 stated he administered seven morning medications for Resident 11. LVN 6 stated Resident 11 was scheduled to have an antibiotic, Levofloxacin (Medication used to treat a variety of bacterial infections), but it was unavailable. A review of Resident 11's Admission Record indicated an original admission dated 11/6/2020 and a readmission on 2/15/2021 with diagnoses including hypertension, history of urinary tract infections, insomnia (difficulty falling or staying asleep), and depression. A review of Resident 11's History and Physical (H&P) Examination (the initial clinical evaluation and examination of the resident) dated 4/25/2021 indicated Resident 11 had the capacity to understand and make decisions. A review of Resident 11's May 2021 MAR was conducted. The MAR for Resident 11 was initialed by a licensed nurse to indicated Resident 11 was administered Levofloxacin and Celebrex (medication to treat moderate pain) on 5/25/2021, at 9 a.m. administration time. During a concurrent interview and record review, on 5/26/2021, at 4:09 p.m., with Medical Records Supervisor (MRS), MRS provided Resident 11's prescription order for Levaquin (medication to treat a variety of bacterial infections) 500 mg, one tablet by mouth daily for seven days, dated 3/17/2021. The MRS stated she had reviewed Resident 11's clinical records and nursing notes, and this was the last Levaquin order she could locate for Resident 11. The MRS further stated there were no nursing notes to indicate Resident 11's physician was called to clarify the Levofloxacin order or determined if the medication was still needed for the resident. During an interview with Resident 11, on 5/27/2021 at 3:54 p.m., Resident 11 stated she was not administered an antibiotic Levofloxacin or Celebrex on 5/25/2021, at 9:00 a.m. administration time. Resident 11 further stated the morning medications received on 5/25/2021 at 9:38 a.m., from LVN 6 were the medications administered while observed by the surveyor and LVN 6 did not return to give additional morning medications. Resident 11 further stated her antibiotic therapy had ended in 4/2021. 3. A review of Resident 269's Admission Record indicated Resident 269 was admitted to the facility on 4/22/2021 with diagnoses including heart failure, hypertension, atrial fibrillation (irregular heartbeat), pulmonary embolism( a blood clot that travels to the lungs), depression, and schizophrenia. A review of Resident 269's H&P, dated 4/24/2021, indicated, Resident 269 did not have the capacity to understand and make decisions. During a medication pass observation on 5/25/2021 at 9:43 a.m., LVN 6 took Resident 269's blood pressure and stated it measured 160 millimeters of mercury (mmHg- unit of measurement) (SBP, systolic blood pressure, the pressure of the blood in the arteries when the heart pumps) over 89 mmHg (DBP, diastolic blood pressure, the pressure between heat beats). According to the American Heart Association Hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes. During a concurrent observation and interview with LVN 6, on 5/25/2021, at 10:04 a.m., LVN 6 stated Resident 269 refused all the morning medications because the Tylenol she requested was not added. LVN 6 further stated Resident 269 always refuse medications and he will change the MAR documentation to resident refused and will waste the seven prepared medications. LVN 6 stated he would circle his initial, which means the resident did not take the medications. LVN 6 was observed placing Resident 269's medications in a sharps container for disposal was in the bottom of his medication cart. LVN 6 stated Resident 269's blood pressure was high (160/89) and acknowledged the medications disposed included blood pressure medications and blood thinners to prevent clots. LVN 6 further stated another medication (Divalproex Sodium [Medication is used to treat certain types of seizures (uncontrollable movement)] 125 mg) scheduled for 9:00 a.m. administration for Resident 269 was unavailable. LVN 6 stated Resident 269 physician was not notified Resident 269 frequently refused morning medications or Divalproex was unavailable for administration to Resident 269. LVN 6 further stated Resident 269's was supposed to receive one more morning medication, however, the medication was unavailable in the medication cart. LVN 6 showed an empty bubble pack (a medication pack with each tablet or capsule individually sealed and labeled with date) labeled for Resident 269 indicated the order was for Divalproex Sodium 125 mg capsule. Medications observed prepared for Resident 269 and wasted by LVN 6 included: i. Furosemide (Medication used to treat fluid retention (edema) and swelling) 20 mg, one tablet ii. Lisinopril (medication to control high blood pressure) 20 mg, one tablet iii. Multiple vitamins (supplement) - One Daily, one tablet iv. Sennosides (used to treat constipation) 8.6 mg, one tablet v. Eliquis (Apixaban, indicated for the prevention of deep vein thrombosis [DVT, blood clot in the leg], which may lead to pulmonary embolism [PE]) 5 mg, one tablet vi. Carvedilol (medication to control high blood pressure) 25 mg, one tablet vii. Tums (Calcium Carbonate, use t