Health inspection·May 6, 2021

F760 § 483.45 (f)(2) Residents are free of any significant medication errors. On 3/2/2021 an unannounced visit was made to the facility to investigate a complaint and a Facility-Reported Incident (FRI) about pharmaceutical services. The facility failed to provide the necessary care and services in accordance with its policies and procedures and professional standards and to ensure Resident 1 was free of significant medication errors on 2/17/2021 and 2/18/2021 when the resident was administered wrong medications. The facility failed to ensure: 1. Registered Nurse 1 (RN 1) verified the name of Resident 1, with the Administrator (ADM), Director of Nursing (DON), or designee, who made the arrangement for Resident 1’s admission. 2. RN 1 verified the discharge instructions (copies of the resident’s medical record from the transferring facility, General Acute Care Hospital 1 (GACH 1), were for Resident 1. 3. RN 1 verified Resident 1’s name, diagnoses and each medication with Attending Physician 1 (AP 1) upon initial admission on 2/17/2021. 4. AP 1, who was responsible for confirming, continuing, changing, or discontinuing medications listed in the discharge instructions, validated each medication as the intended medication for Resident 1. 5. RN 1 transcribed the correct set of medications in the Medication Administration Record (MAR - a record of medications administered to residents) for Resident 1 upon admission. As a result, Resident 1 received nine medication for a total of nine doses that were intended for an unknown patient. Resident 1 missed a total of 14 medications for a total of 25 missed doses between 2/17/2021 and 2/18/2021, placing the resident at risk of severe health complications. A review of Resident 1's Admission Record, dated 3/6/2021, indicated he was admitted to the facility on 2/17/2021 with a diagnosis of angina pectoris (a disease marked by chest pain) and heart failure (heart doesn't pump blood as well as it should). A review of Resident 1's MAR dated 2/17/2021 and 2/18/2021 indicated the medication listed on Resident 1's discharge instructions dated 2/17/2021, from GACH 1 were not ordered at SNF 1 until after 4 p.m. on 2/18/2021 (23 hours after the resident first arrived at the facility). A review of Resident 1's Physician Order's and MAR dated 2/17/2021 and 2/18/2021 indicated that the resident did not receive 14 medications for a total of 25 missed doses as prescribed and intended as follows: 1. Amlodipine Besylate (a medication used to treat high blood pressure) tablet (tab) 2.5 milligrams (mg - unit of measure) give one tab by mouth daily, ordered 2/18/2021 at 4:59 p.m. Dose not given on 2/18/2021 for 9 a.m. 2. Aspirin (a medication to reduce the risk for stroke [damage to the brain from interruption of its blood supply] 81 mg tab chewable, give one tab by mouth daily, ordered 2/18/2021 at 4:59 p.m. Dose not given on 2/18/2021 for 9 a.m. 3. Clopidogrel bisulfate (a medication used to reduce the risk of blood clots) tab 75 mg give 1 tab by mouth daily, ordered 2/19/2021 at 4:59 p.m. Dose not given on 2/18/2021 for 9 a.m. 4. Finasteride (a medication used to treat benign prostatic hyperplasia [BPH], the enlargement of the prostate gland which causes urination difficulty) tab 5 mg give one tab by mouth daily, ordered 2/18/2021 at 4:50 p.m. Dose not given on 2/18/2021 for 9 a.m. 5. Furosemide (a medication for reducing swelling) tab 40 mg give 1 tab by mouth, daily, ordered on 2/18/2021 at 4:59 p.m. Dose not given on 2/18/2021 for 9 a.m. 6. Glipizide xl (a medication used to treat diabetes [uncontrolled sugar levels in the blood]) tab extended release 24-hour (medication that is released slowly over a period of time within the body) 5 mg, give one tab by mouth daily with breakfast, ordered on 2/18/2021 at 4:59 p.m. Dose not given on 2/18/2021 for 7:30 a.m. 7. Tamsulosin Hydrochloride (a medication used to treat BPH) capsule (cap) 0.4 mg, give one cap by mouth, daily, ordered on 2/18/2021 at 4:59 p.m. Dose not given on 2/18/2021 for 9 a.m. 8. Gemfibrozil (a medication used to treat abnormally high levels of fats in the blood) tab 300mg by mouth, two times a day, ordered on 2/18/2021 4:59 p.m. Doses not given on 2/18/2021 for 9 a.m. and 5 p.m. 9. Hydralazine Hydrochloride (a medication used to treat high blood pressure) 10 mg tab by mouth twice a day, ordered on 2/18/2021 at 4:59 p.m. Doses not given on 2/18/2021 for 9:00 am and 5:00 p.m. 10. Isosorbide Dinitrate (a medication for chest pain) Tablet, give 20 mg by mouth two times a day, ordered on 2/18/2021 at 4:59 p.m. Doses not given on 2/18/2021 for 9 a.m. and 5 p.m. 11. Metoprolol Tartrate (a medication for high blood pressure) tab, 25 mg give one tab by mouth twice a day, ordered on 2/18/2021 at 4:59 p.m. Doses not given on 2/18/2021 for 9 a.m. and 5 p.m. 12. Omega 3 (a medication used as a supplement to reduce the risk of heart disease) cap 1000 mg, give one cap by mouth, two times a day, ordered on 2/18/2021 at 5:19 p.m. Doses not given on 2/18/2021 for 9 a.m. and 5 p.m. 13. Combivent Respimat Aerosol Solution (an inhaled medication used to treat breathing problems) 20-100 microgram(mcg-unit of measure)/actuation(act-mouthpiece), one puff inhale orally four times per day, ordered 2/18/2021 at 5:19 p.m. Doses not given on 2/17/2021 for 9 p.m. and on 2/18/2021 for 9 a.m., 1 p.m. and 5 p.m. 14. Methadone Hydrochloride (a medication used to treat moderate to severe pain) solution 10mg/5milliliters (ml-unit of measure) give 5ml by mouth, three times a day for seven days, ordered 2/18/2021 at 7:36 p.m. Doses not given on 2/18/2021 for 9 a.m., 1 p.m. 5 p.m. and on 2/19/2021 for 9 a.m. On 3/2/2021 at 3:10 p.m., during an interview, RN 1 stated that she admitted Resident 1 to the facility on 2/17/2021 at around 5 p.m. RN 1 stated she called AP 1 to conduct a medication reconciliation (the process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications) for Resident 1. RN 1 stated that she was told by AP1 to continue all medications listed on the discharge instructions without changes. RN1 confirmed that she did not conduct a thorough medication reconciliation when she failed to verify each of the medications listed on the discharge instruction with AP1. On 3/22/2021 at 3:03 p.m., RN 1 stated that while conducting Resident 1's medication reconciliation, she noted two sets of discharge instructions from GACH 1 in Resident 1's chart. RN 1 stated that one set of discharge instruction was in Spanish, while the other was in English. RN 1 stated she did not compare the two sets of the discharge instructions to ensure that the information matched. RN 1 stated that she did not verify the name written on the English version of the discharge instructions when she entered the medication list into Resident 1's medical records. RN1 stated ultimately she entered the wrong medications into Resident 1's physician orders as the set of discharge instructions that were in English belonged to an unknown patient. RN1 stated if she had gone through each medication with the doctor, this error could have been avoided. RN1 stated that receiving the wrong medications could have potentially caused severe harm to Resident 1. A review of Resident 1's Physician’s Orders and MAR dated between 2/17/2021 and 2/18/2021 indicated a total of nine doses of the following medications, not intended for the resident, were administered to him in error: 1. Ascorbic Acid (a medication used for anemia [blood lacks healthy red blood cells]) 500 mg one tab by mouth in the morning with an order date of 2/17/2021 at 6:02 p.m. One dose given on 2/18/2021 at 9:00 a.m. 2. Magnesium Oxide (a medication used to supplement low levels of magnesium) 400 mg given by mouth in the morning with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/18/2021 at 9:00 a.m. 3. Polyethylene Glycol (a medication used to treat constipation [inability to have bowel movements] 17 grams (gm-unit of measure) one packet by mouth at bedtime with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/17/2021 at 9:00 p.m. 4. Carvedilol (a medication used to treat high blood pressure) 3.125 mg given one tab by mouth twice a day with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/18/2021 at 9:00 a.m. 5. Famotidine (a medication used to treat heartburn) 20 mg give one tablet by mouth twice a day with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/18/2021 at 9:00 a.m. 6. Lacosamide (a medication used to treat seizures [ sudden, uncontrolled electrical disturbance in the brain]) 100 mg give one tablet by mouth twice a day with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/18/2021 at 9 a.m. 7. Levetiracetam (a medication used to treat seizures) 100 mg per ml, give 20 ml by mouth two times a day with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/18/2021 at 9 a.m. 8. Phenytoin Suspension (a medication used to treat seizures) 25 mg per ml, give 7 ml by mouth three times a day with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/18/2021 at 9 a.m. 9. Senna Docusate Sodium (a medication used as a stool softener) 8.6 mg-50 mg give two tablets by mouth twice a day with an order date of 2/17/2021 at 6:02 p.m. One dose was given on 2/18/2021 at 9 a.m. On 3/22/2021 at 3:55 p.m., during an interview and concurrent record review, the DON stated that during a review of Resident 1's discharge instructions on 2/18/2021, they discovered that RN 1 had transcribed the wrong medications on to Resident 1's physician's orders which then transcribed those wrong medications on to the resident's MAR. DON stated that they received two sets of discharge instructions from GACH 1 during Resident 1's admission, one in English and one in Spanish. DON confirmed that the set of discharge instructions in English indicated a different unknown patient's name on it. DON stated it was identified that RN 1, after speaking to AP 1, transcribed this unknown patient's discharge instructions as new physician's orders on to Resident 1's medical records. DON reviewed Resident 1's MAR for 2/17/2021- to 2/18/2021 and verified that Resident 1 received a total of nine doses of medications in error and did not receive 14 medications for a total of 25 missed doses as prescribed and intended. DON stated the name on GACH 1's discharge instructions should have been checked prior to being recorded on to the physician's orders and the MAR for accuracy to ensure the right medications were administered to the right resident. DON verified the nine morning medications provided to Resident 1 matched the medications on the discharge instructions of the unknown patient received from GACH 1. On 3/22/2021 at 2:23 p.m., during a telephone interview, the Medical Director (MD 1) confirmed that Resident 1 received medications that were intended for an unknown patient, including several seizure medications. MD 1 stated the RN 1 and AP 1 failed to follow the facility's policy and procedure in ensuring that the medications were appropriate for the resident. MD 1 stated that although this resident seemed unharmed, the harm could have been much worse if different medications were involved. On 3/22/2021 at 3:03 p.m., during an interview, RN 1 stated the usual practice is to go over each medication with AP 1 and then AP 1 would confirm either to continue, change or discontinue each medication listed in the discharge instructions upon resident's admission. RN 1 stated there have been times when AP 1 would instruct RN 1 to continue all medications without going over each medication. RN 1 stated that not going over each medication for a resident could result in potential severe harm to the resident. On 3/22/2021 at 3:25p.m., during an interview, the DON stated that most of the time, attending physicians would just instruct the licensed nurses verifying the discharge instructions including the list of medications to continue all orders and they will come by within 72 hours to check the orders. DON further stated that sometimes admissions occur late in the night and the doctors do not like to be bothered if it is not an emergency and will say to continue all orders received from the hospital. On 3/22/2021 at 3:40 p.m., during an interview, ADM acknowledged RN 1 did not go over each of Resident 1's medication list in the discharge instructions with AP 1 during admission. ADM stated that physicians will not give the time to go through each individual order and it should be done. ADM stated that both AP 1 and RN 1 failed to follow the facility's policy and procedure regarding the verification of accurate medication orders for Resident 1. On 3/22/2021 at 3:55 p.m., during an interview over the phone, AP 1 confirmed that upon admission of Resident 1 to the facility, the medication reconciliation was not reviewed upon admission. AP 1 stated he did not discuss each medication or their indications with RN 1 prior to continuing the medications. AP 1 stated that usually the nurses and providers are busy and do not have time to address each medication separately. AP 1 stated that in medicine mistakes are made and it is important to be honest about them to make sure they do not happen again. AP 1 stated that RN 1 made an error by not checking the name on the discharge instructions prior to entering them and the facility addressed with nursing staff the necessity to check each order with the physician prior to entry into the medical record to ensure accuracy and appropriateness for each resident. A review of the facility's policy and procedure titled "Medication Orders", dated 4/2008, indicated that with written transfer orders (sent with a resident by a hospital or other health care facility): 1. "If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered." 2. "Obtain the indication for each medication ordered." 3. "The prescriber renews the order either by repeating the entire order process or with a statement such as "continue XXX for ten days." The prescriber writes a new order for continued therapies that require a change in directions, dosage form, or strength." A review of the facility's undated policy and procedure document titled "Med Pass" indicated to ensure that medications are administered according to the right resident and right medication. The facility failed to provide the necessary care and services in accordance with its policies and procedures and professional standards of practice when not administering the correct medications to Resident 1 between 2/17/2021 and 2/18/2021. The facility failed to ensure: 1. RN 1 verified the name of Resident 1, with the ADM, DON, or designee, who made arrangement for Resident 1’s admission. 2. RN 1 verified the discharge instructions from the transferring facility, GACH 1, were intended for Resident 1. 3. RN 1 verified Resident 1’s name, diagnoses and each medication with AP 1 upon initial admission on 2/17/2021. 4. AP 1, who was responsible for confirming, continuing, changing, or discontinuing medications listed in the discharge instructions, validated each medication as the intended medication for Resident 1. 5. RN 1 transcribed the correct set of medications in the MAR for Resident 1 upon admission. As a result, Resident 1 received nine medication for a total of nine doses that were intended for an unknown patient. Resident 1 missed a total of 1