Legacy Park Health And Rehabilitation

Review of a Medication Removal Form Emergency Kit After Hours form for Resident #7 dated 8/8/2024 and faxed to the pharmacy on 8/8/2024 at 11:46 PM, revealed Morphine 20 mg/1 ml 0.25 by mouth routine.

Review of a Medical Record Review (MRR) for Resident #7 dated 8/9/2024, revealed Pharmacist A completed a MRR for Resident #7 listing no recommendations.

Pharmacist A failed to identify the inaccurate transcription of Resident #7's Morphine Sulfate order.

During an interview on 2/21/25 at 4:30 PM, the Director of Nursing (DON) stated Licensed Practical Nurse (LPN) A transcribed Morphine Sulfate 20 mg per 5 ml, give 0.25 ml or 1mg buccally every 2 hours for pain/SOB and another order for Morphine Sulfate 20 mg per 5 ml give 0.25 ml or 1 mg by mouth at bedtime for pain into the electronic medical record (EMR), and this was incorrect.

She stated the facility nurse faxed the Drug Receipt/Record/Disposition Form and Medication Removal From Emergency Kit After Hours form to the pharmacy with the correct concentration dose but incorrect frequency on 8/8/2024 and the MRR conducted by Pharmacist A did not catch the morphine error despite receiving orders from the hospice agency, the Drug Receipt/Record/Disposition Form and Medication Removal From Emergency Kit After Hours form from the facility.

During an interview on 2/27/24 AT 11:00 AM, Pharmacist A stated the process for hospice patients is for the pharmacy to put orders into a profile.

The orders the pharmacy puts into the profile populates into a web-based program the contracting pharmacists use to complete the MRR.

Pharmacist A confirmed the profile entered by the pharmacy into the shared program was Morphine 100 mg/5 ml give 0.25 ml or 5 mg every 2 hours PRN.

Pharmacist A stated on 8/8/2024 the facility removed Morphine 100 mg/ 5 ml or 20 mg per 1 ml give 0.25 ml or 5 mg every 2 hours routinely from the emergency narcotic box.

Pharmacist A stated this was faxed to the pharmacy and considered a new order.

Pharmacist A stated the facility has 7 days to send the pharmacy a new signed prescription (script) by the provider to have on file.

Pharmacist A stated he performed his MRR on 8/9/2024 and the MAR in the EMR reads Morphine 20 mg per 5 ml give 0.25 ml q 2 hours routine.

Pharmacist A confirmed he should have caught the incorrect concentration, and he missed it.

Pharmacist A stated he didn't question the frequency because a hospice patient going from PRN to scheduled morphine is not unusual.

Pharmacist A stated he is not certain if the MAR is rechecked once the facility sends the signed script to the pharmacy, or if the order in the profile is changed.

Pharmacist A stated once he completes his original admission MRR his portion is finished, and he doesn't see any other orders.

445105 02/27/2025

Legacy Park Health and Rehabilitation 7424 Middlebrook Pike Knoxville, TN 37909

investigation was conducted, and a Performance Improvement Plan (PIP) was put in place.

The DON

ordered and transcribed as scheduled, not PRN.

This surveyor and the DON discussed all

to getting Morphine 5mg every 2 hours instead of PRN.

The DON stated the service hospice pays for gives patients a certain number of respite days per year.

She confirmed the facility only conducts a skin assessment and administers medications and treatments on respite hospice patients admitted to the facility.

The DON confirmed there were no nursing assessments or vital signs completed on Resident #7 and no indication of how getting 5 mg of Morphine every 2 hours effected Resident #7.

This surveyor and the DON reviewed Hospice documentation.

The DON was not aware the hospice service had been in the facility twice on 8/12/2024, once for a routine visit and again at the family's request due to concerns regarding Resident #7's behavior and level of consciousness (LOC).

This surveyor asked the DON why she was not aware the hospice agency was in the facility the day prior Resident #7's discharge, the DON stated hospice should have communicated the fact they were in the facility to staff, and this was not done.

Refer to F-F684, F-F756, F-F760 and F-F867

445105 02/27/2025

Legacy Park Health and Rehabilitation 7424 Middlebrook Pike Knoxville, TN 37909

Review of the medical record for Resident #10 revealed a SBAR communication tool was not in the medical record.

During an interview on 2/21/2025 at 2:20 PM, the Director of Nursing (DON) confirmed staff were expected to document resident's urine output and indwelling catheter changes in the medical record and confirmed staff were expected to complete a SBAR communication tool for resident's who were transferred to the ER.

The DON confirmed Resident #2's urine output, and a catheter change performed for Resident #2 on 12/4/2024 had not been documented in the medical record and confirmed a SBAR communication tool was not completed when Resident #10 was transferred to the ER on [DATE].

During an interview on 2/21/2025 at 4:00 PM, the Assistant Director of Nursing (ADON) confirmed urine output had not been documented in the medical record for Resident's #17, #18, and #19.

445105 02/27/2025

Legacy Park Health and Rehabilitation 7424 Middlebrook Pike Knoxville, TN 37909

facility on 8/13/2024 by LPN C who discussed the issue with Resident #7's daughter.

The DON stated

to include the DON, ADON, Unit Manager, MDS Nurse, and Wound Care Nurse.

The DON stated her

and transcribed as scheduled, not PRN.

The DON stated no harm came to the resident except that the patient's daughter reported her mother was drowsy.

The DON stated her corrective action was to correct the Morphine order on 8/13/2024 prior to discharge but just realized today the concentration on the corrected order was incorrect.

The DON stated measures taken to prevent recurrence of this incident were to educate LPN B, note the format of hospice orders and to ensure staff were looking at the PRN column.

The DON stated orders were still transcribed by a staff nurse, checked by another nurse, an MRR was still completed within 3 days and now the DON and ADON check all resident orders.

The DON stated they perform routine random audits as well, but these audits were not documented anywhere, and she had no record of audits being completed.

The DON stated LPN B was educated on her mistake.

The DON stated she did not educate the agency nurse who transcribed the morphine incorrectly because she was not her (facility) employee.

The DON stated she did not educate any other staff nurses on medication errors and did not include hospice, agency or pharmacy in her PIP.

The DON confirmed the QAPI Committee had identified a significant medication error as an area of concern for the facility but was not aware of the extent of the problem.

Continued interview confirmed the facility failed to perform a root cause analysis or thorough investigation for the significant medication error as the errors in morphine concentration were not identified even after the error was caught.

Further interview confirmed the facility failed to implement an effective plan to mitigate errors in transcribing orders by not including facility or agency staff nurses responsible for transcribing orders and not communicating the need for clear concise hospice orders with the hospice agency.

The QAPI Committee failed to ensure an effective Quality Assurance Program was in place to monitor and evaluate concerns related to significant medication errors.

Refer to F-F684, F-F756, and F-F760.

F-F760.

445105

Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 2001, revealed . promptly notifies .his or her attending physician .changes in the resident's medical/mental condition and/or status .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including .information prompted by the Interact SBAR [situation, background, assessment, recommendation] Communication Form .

Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Neuromuscular Dysfunction of Bladder, Hemiplegia/Hemiparesis, and Vascular Dementia.

Review of a baseline care plan dated 11/21/2024, revealed Resident #2 had an indwelling urinary catheter.

Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated moderate cognitive impairment.

Continued review revealed Resident #2 had an indwelling urinary catheter.

Review of a 7:00 PM-7:00 AM shift report dated 12/4/2024, revealed Resident #2's indwelling urinary catheter was changed during the shift.

Review of a nurse's note for Resident #2 dated 12/5/2024 at 11:30 AM, revealed Resident #2 reported the indwelling urinary catheter had been replaced on 12/4/2024 at approximately 11:00 PM.

Review of the medical record for Resident #2 from 11/21/2024-12/5/2024 revealed no documentation the resident's indwelling urinary catheter had been replaced.

Review of the medical record for Resident #2 revealed there was no documentation of the resident's urine output from 11/21/2024-12/5/2024.

Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Pressure Ulcer of Sacral Region, Unspecified Stage.

445105

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 445105 B.

Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale Health Care Center 7424 Middlebrook Pike Knoxville, TN 37909