Other·August 5, 2022

F760 §483.45(f)(2) Residents are free of any significant medication errors. The facility must ensure that its residents are free of any significant medication errors. T22 Section 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. T22 Section 72313. Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. On 5/10/22, the Department of Public Health conducted a facility reported incident investigation regarding patient abuse. The facility failed to ensure Patient 1 was free of any significant medication errors by failing to administer the correct dose of Lexapro (medication used to treat depression and anxiety disorders) to Patient 1 in accordance with the physician’s order and obtain an order to administer normal saline (NS, a mixture of sodium chloride and water) in accordance with the discharge summary from General Acute Care Hospital 1 (GACH 1). This violation placed Patient 1 at risk for adverse (harmful) side effects of Lexapro and dehydration (a condition where the body does not have enough water and other fluids to carry out normal functions) that could lead to an overall negative impact on Patient 1's physical, mental, and psychosocial well-being. A review of Patient 1's Admission Record, indicated the facility admitted Patient 1 on 3/4/22. Patient 1 is a 72-year-old female with diagnoses including COVID-19 (Coronavirus, a severe respiratory illness caused by a virus and spread from person to person), bipolar disorder (a mental disorder that causes extreme mood swings that include emotional highs and lows), depression, anxiety disorder, and psychotic disorder (a mental disorder characterized by a disconnection from reality) with delusions (false belief). A review of Patient 1's Discharge Summary from GACH 1 dated 3/4/22, indicated the following orders: 1. Continue normal saline at 50 milliliters per hours (ml/hr) intravenously (through or within a vein) for two days (indication not specified). 2. Lexapro 5 milligrams (mg) by mouth daily (indication not specified). A review of Patient 1's List of Home Medications from GACH 1 dated 3/4/22, indicated Patient 1 received Lexapro 5 mg by mouth daily. A review of Patient 1's Admission/Readmission Data Collection dated 3/4/22, indicated the patient was assessed being alert to person, disoriented to place and time, usually able to communicate with unclear speech, and required extensive assistance with activities of daily living. The admission assessment indicated the patient was assessed being calm and cooperative and was receiving antipsychotic, antianxiety, and antidepressant medications. A review of Patient 1's Physician Order dated 3/4/22, indicated for the patient to receive Lexapro 10 mg, one tablet by mouth one time a day for depression. A review of Patient 1's Baseline Care Plan dated 3/7/22, indicated the facility read the list of Patient 1's medications to Patient 1's Family Member 1 (FM 1) and FM 2. FM 1 and FM 2 agreed and verified all the patient's medications. A review of Patient 1's Medication Administration Record (MAR) for March 2022, indicated Licensed Vocational Nurse 1 (LVN 1) administered and initialed the patient's MAR on two separate boxes with both boxes indicating to give the patient Lexapro 10 mg, one tablet one time a day for depression on 3/5/22 (a total of 20 mg) and 3/6/22 (a total of 20 mg). During a telephone interview on 6/28/22 at 8:54 AM, the Quality Assurance (QA) Nurse stated for new patient admissions from the hospital, the admitting nurse would review the discharge summary from the hospital, including the patient's medication orders, and verify the orders with the admitting physician or the nurse practitioner (NP). The admitting physician or NP would then authorize continuation of care and give orders. The QA Nurse stated once the admitting nurse verifies the orders, the admitting nurse will type the orders directly in the computer system. The QA Nurse stated the Director of Nurses (DON) and the Medical Records Director would then review the physician orders and do an audit the morning after the admission. During an attempted telephone interview on 6/28/2022 at 9:35 AM, LVN 1 did not answer the phone and did not return the call. During an interview on 6/28/22 at 2:18 PM, LVN 2 stated for new patient admissions from the hospital, the facility would get a packet from the discharging hospital containing all information about the patient such as name, history and physical, reason for hospitalization, list of medications, allergies, and family contact information. The nurse would review and read the list of medications to the physician or the NP over the phone and the physician or the NP would say if he or she would want to continue or discontinue the medication. LVN 2 stated usually the physician or the NP would continue the same orders from the discharging hospital. LVN 2 stated the nurse would then inform the patient or the patient's responsible party of the physician orders and put the orders in the computer system. LVN 2 stated he does not remember Patient 1 and does not remember putting the patient's admission orders in the system. During a second attempted telephone interview on 6/29/2022 at 11:43 AM, LVN 1 did not answer the phone and did not return the call. During a telephone interview on 6/29/22 at 4:11 PM, the DON stated the facility would get the paperwork from the discharging hospital including the medication reconciliation sheet upon the patient's admission to the facility. The charge nurse would contact the attending physician to read the list of medications and obtain admission orders. The attending physician would then order to continue, discontinue, or change the medications. During a telephone interview on 6/30/22 at 9:56 AM, Physician 1 stated he was Patient 1's attending physician. Physician 1 stated the patient was only in the facility for three or four days then became more confused and was transferred to GACH 1. Physician 1 stated the patient was treated for a urinary tract infection at GACH 1 and was discharged to a different facility. Physician 1 stated it was NP 1 who gave the admission orders (on 3/4/22). Physician 1 stated he usually would continue the discharge orders from the hospital and continue the same medication orders. Physician 1 stated as far as he can recall, he and NP 1 did not order any increase in the dose of the Lexapro. During a telephone interview and concurrent review of Patient 1's Home Medications List and Discharge Summary from GACH 1 on 6/30/22 at 11:05 AM, the DON stated the patient's discharge orders from GACH 1 included to continue Lexapro 5 mg by mouth daily and NS at 50 ml/hr for two days. The DON stated the admission orders dated 3/4/22, indicated Lexapro 10 mg by mouth daily instead of 5 mg. The DON stated there was no evidence NS was ordered in accordance with the discharge summary from GACH 1. The DON stated she could not explain the changes in the orders because it was a communication between the admitting nurse and the attending physician. The DON stated maybe the attending physician recommended to increase the Lexapro dose and discontinue the NS. The DON could not provide a documented indication to explain the increase in the dose of the Lexapro and rationale for discontinuing the NS. The DON reviewed Patient 1's MAR and stated the MAR had two orders for Lexapro 10 mg by mouth daily. The DON stated LVN 1 signed for the Lexapro twice on 3/5/22 and 3/6/22. The DON stated when administering medications, the licensed nurse should always check for the five rights of medication administration before giving medications and signing the MAR. A review of the facility's policy and procedures titled, "Admission Assessment and Follow Up: Role of the Nurse," revised in 9/2012, indicated to conduct an admission assessment (history and physical), including: current medications and treatments. The policy indicated to reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. A review of the facility's policy and procedures titled, "Administering Medications," revised in 4/2019, indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right patient, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The policy indicated the individual administering the medication initials the patient's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the patient's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. The facility failed to ensure Patient 1 was free of any significant medication errors by failing to administer Lexapro (medication used to treat depression and anxiety disorders) and normal saline (NS, a mixture of sodium chloride and water) to Patient 1 as ordered by the physician. This violation placed Patient 1 at risk for adverse (harmful) side effects of Lexapro and dehydration (a condition where the body does not have enough water and other fluids to carry out normal functions) that could lead to an overall negative impact on Patient 1's physical, mental, and psychosocial well-being. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.