Health inspection·July 19, 2024

The facility must ensure that its— 42 CFR §483.45(f)(2) Residents are free of any significant medication errors. On 6/7/2024, an unannounced visit was made to the facility to investigate a complaint regarding quality of care. The facility failed to ensure that Resident 1 was kept free from significant medication error (the administration of medication, or omission of a medication that endangers the health and safety of a resident), when on 5/30/2024, Student Nurse 1 (STU 1) administered medications to Resident 1 that were intended for Resident 2. As a result, Resident 1 received three (3) medications that were intended for Resident 2 and placed Resident 1 at increased risk of severe health complications including hallucinations (false perception; the experience of seeing, hearing, feeling, or smelling something that does not exist), mood changes (such as agitation [feeling of irritability or restlessness]), and could possibly lead to hospitalization or death. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1 on 4/29/2024 and re-admitted Resident 1 on 5/16/2024 with diagnoses that included metabolic encephalopathy (a medical problem such as blood infections or liver or kidney failure causing brain damage), chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems), and congestive heart failure (heart can’t pump enough blood to keep up with the body’s need). A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/3/2024, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS further indicated that Resident 1 required moderate assistance from staff with oral hygiene, upper body dressing, and personal hygiene. The MDS indicated that Resident 1 was dependent on staff with toileting and lower body dressing. A review of the Physician’s Orders for Resident 1 indicated the following orders: 1. Amitiza (a medication used to treat constipation [problem with passing stool]) 24 micrograms (mcg- unit of measure) give one capsule by mouth two times a day, with an order date of 5/16/2024. 2. Donepezil Hydrochloride (a medication used to treat dementia [loss of cognitive [mental process involved in knowing, learning, and understanding things] functioning) 10 milligrams (mg- unit of measure) give one tablet my mouth one time a day, with an order date of 5/16/2024. 3. Magnesium Oxide (a medicine that relieves heartburn and indigestion [uncomfortable inability or difficulty in digesting food]) 400 mg give one tablet by mouth one time a day, with an order date of 5/16/2024. 4. Plavix (a medication used to reduce the risk of heart disease [when the body cannot deliver enough oxygen-rich blood to the heart] and stroke [a life-threatening medical condition that happens when the blood supply to part of the brain is cut off]) 75 mg give one tablet by mouth one time a day, with an order date of 5/16/2024. 5. Potassium Chloride Liquid (a mineral supplement used to treat or prevent low amounts of potassium in the blood) 20 milliequivalent (mEq- unit of measure) per 15 milliliters (ml- unit of measure), give 20 mEq by mouth two times a day, with an order date of 5/16/2024. 6. Vitamin D3 (a vitamin supplement for bones, muscles, nerves and to support the immune system [a complex network of cells, tissues, organs, and the substances they make that helps the body fight infections and other diseases) 25 mcg give one tablet by mouth three times a day, with an order date of 5/21/2024. 7. Megestrol Acetate Suspension (used to treat loss of appetite and weight loss) 400 mg per ml, give 10 ml one time a day for two weeks, with an order date of 5/22/2024. A review of Resident 1’s COC Note dated 5/30/2024 timed at 2:45 p.m. indicated on 5/30/2024 at around 1:00 p.m., Licensed Vocational Nurse (LVN) teacher (Instructor 1 [INS 1]) reported to the DON that an LVN student (STU 1) gave medications in error to Resident 1. The COC Note further indicated that Resident 1 will be monitored for any side effects (undesirable effect of a medication) such as episodes of nausea, dizziness, headache, hallucinations, and orthostatic hypotension. The COC Note indicated that the charge nurse (Licensed Vocational Nurse 1 [LVN 1]) and INS 1 placed a call to MD 1 on 5/30/2024 at 1:37 p.m. informing MD 1 of the medications given in error to Resident 1. MD 1 ordered to obtain STAT CBC and CMP and to monitor Resident 1 for any adverse effect of medications every shift. A review of Resident 2’s Admission Record indicated the facility originally admitted Resident 2 on 7/7/2021 and re-admitted Resident 2 on 5/16/2024 with diagnoses that included parkinsonism (a brain disorder that causes unintended or uncontrollable movements, rigidity [stiffness] and tremors [trembling or shaking]), and hypertension (high blood pressure). A review of Resident 2’s MDS dated 5/20/2024, indicated Resident 2 had intact cognition. The MDS further indicated that Resident 2 required moderate assistance from staff with eating, oral hygiene, personal hygiene. The MDS indicated that Resident 2 was dependent on staff with toileting hygiene, shower or bathing, and dressing. A review of the Physician’s Order for Resident 2 indicated the following orders: 1. Carbidopa-Levodopa (combination medication used to treat symptoms of Parkinson’s disease [a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination]) 25-100 mg give two tablets by mouth three times a day (9:00 a.m., 1:00 p.m. and 5:00 p.m.), with order date of 5/16/2024. 2. Pramipexole Dihydrochloride (a medication used to treat Parkinson’s disease) 0.5 mg give one tablet by mouth three times a day (9:00 a.m., 1:00 p.m. and 5:00 p.m.), with order date of 5/16/2024. 3. Sodium Chloride (a medication used for low blood pressure) 1000 mg by mouth three times a day (9:00 a.m., 1:00 p.m. and 5:00 p.m.), with order date of 5/17/2024. During an interview with INS 1 on 6/7/2024 at 3:50 p.m., INS 1 stated that on 5/30/2024 at around 1:00 p.m., INS 1 was with STU 1. INS 1 stated that STU 1 prepared Resident 2’s due medications for 1:00 p.m. INS 1 stated that STU 1 prepared Resident 2’s Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg. INS 1 stated that after STU 1 prepared Resident 2’s medications, STU 1 then entered both Resident 1 and Resident 2’s room. INS 1 stated that rather than staying by STU 1’s side to observe the medication administration that was intended for Resident 2, INS 1 instead began assisting Student Nurse 2 (STU 2) with medication preparation. INS 1 stated that while INS 1 was assisting STU 2, STU 1 informed INS 1 that STU 1 erroneously administered the three medications (Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg) of Resident 2 to Resident 1. INS 1 stated that INS 1 should have accompanied STU 1 to administer medications to Resident 2 to supervise the medication administration. During an interview with the DON on 6/10/2024 at 1:30 p.m., the DON stated on 5/30/2024 at around 1:00 p.m. INS 1 informed the DON that STU 1 administered three medications (Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg) intended for Resident 2 to Resident 1. The DON stated that it is the facility’s responsibility to ensure resident’s safety at all times. The DON stated that the medication error involving Resident 1 that occurred on 5/30/2024 could have been avoided if INS 1 accompanied STU 1 into Resident 2’s room to observe and supervise the actual administration of medications. The DON further stated that STU 1 should have confirmed the identification of Resident 1 by first checking the wristband of the resident, the photograph of the resident that is attached in the resident’s medical record, asking the resident to identify themselves, and or verifying the identification of the resident prior to the administration of medications. During an interview with MD 1 on 6/10/2024 at 1:55 p.m., MD 1 stated that headache, nausea, dizziness, hallucinations, and orthostatic hypotension are possible adverse reactions (unwanted, undesirable effects related to medications) as a result of Resident 1 being given the three medications (Carbidopa-Levodopa 25-100 mg two tablets, Pramipexole 0.5 mg one tablet and Sodium Chloride 1000 mg) intended for Resident 2. A review of the Clinical Affiliation Agreement (a contract between the nursing school and the facility that creates an obligation to perform a particular duty) with an effective date of 10/5/2023, signed by the Assistant Contract Manager of the Institution (nursing school) on 11/17/2023, and the facility’s ADM on 11/29/2023, indicated that the Institution will inform and explain to students that during their clinical rotation at the facility, each student will be under the guidance of facility managers, director and administrator; and each student must follow the rules, policies and procedures of the facility, to the fullest extent, to ensure a safe environment for the facility’s residents, the institution’s students, and the employees of the facility. A review of the facility’s policy and procedure titled “Medication Administration- General Guidelines” last reviewed on 3/11/2024, indicated that medications are administered as prescribed in accordance with good nursing principles and practices. Medications are administered in accordance with written orders of the attending physician. Residents are identified before a medication is administered. Methods of identification include: a. Checking identification band. b. Checking photograph attached to medical record. c. If necessary, verifying resident identification with other personnel. The facility failed to ensure that Resident 1 was kept free from significant medication error, when on 5/30/2024, STU 1 administered medications to Resident 1 that were intended for Resident 2. As a result, Resident 1 received three (3) medications that were intended for Resident 2 and placed Resident 1 at increased risk of severe health complications including hallucinations, mood changes, and could possibly lead to hospitalization or death. The above violations had a direct relationship to the health, safety, or security of Resident 1.