- Date
- 7/7/2025
- Report number
- CALMS - 00084007
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 07/15/25, the facility's failure to ensure that a resident monitoring and reporting system is implemented 24 hours a day was substantiated for 1 of 1 sampled resident (#1). This posed an immediate jeopardy situation, which put the health and safety of residents at risk.
Findings include, but are not limited to:
Compliance Specialist (CS) was unable to interview Resident 1 or make observations as s/he was no longer in the facility.
The facility’s policy and procedure for medication and treatment orders dated 05/01/25, indicated the following:
If a resident misses a medication due to the medication being unavailable, the med tech must document on the MAR the applicable medication and efforts to obtain them. Staff should attempt to obtain medication immediately and follow up until the issue has been resolved. Notify the Nurse, ED, and prescriber for medications not given due to being unavailable; Place the resident on alert charting and include what has been done or needs to be followed up on to get the medication in the community in the alert charting entry; Put an ISP in place to note what needs to be monitored by staff due to the missed medication; Refills must be ordered before a medication reaches a seven-day supply; Once refills have been requested, each shift must follow up until the medication arrives; Document all efforts made to obtain medications timely, including phone calls, faxes, non-coverage notices, and coordinate with the prescriber or pharmacy; Any medications requested but not received require immediate follow-up.
A review of Resident 1’s progress notes dated 06/01/25 through 07/12/25 indicated the following:
There had been no alert charting or monitoring for missed medications; There had been no chart notes indicating the facility's efforts to obtain the necessary medications; On 07/03/25, the med tech called the PCP’s office at 9:45 am regarding refills of the Eliquis and Metoprolol medication; On 07/03/25, the updated E-Rx was received for Metoprolol, MAR order was verified to match the E-script; On 07/08/25 the resident was sent out to the hospital on 07/07/25 with a confirmed stroke on 07/08/25; On 07/09/25, the resident returned from the hospital; and On 07/12/25, the resident had passed away on 07/11/25.
Fax communication from the facility to the pharmacy and physician indicated the following:
On 06/24/25, the facility inquired to refill Resident 1’s Metoprolol 50 mg prescription; On 06/25/25, the facility inquired to refill Resident 1’s Eliquis 2.5 mg prescription; and On 07/02/25, the facility followed up with the request to fill both Metoprolol 50 mg and Eliquis 2.5 mg. Stating, “Resident has been out for a week.”
An incident report dated 07/09/25 indicated the facility nurse was notified by the med tech that the resident had been sent to the hospital for a possible stroke on 07/07/25. The nurse received an update from family/hospital regarding the resident's stroke when the evening shift med tech asked if his/her medications were related to the stroke. The nurse asked what the med tech meant. Med tech then stated that the resident had been missing his/her morning dose of 2.5mg Eliquis since 06/26/25. The nurse had not been notified that s/he was out of the medication. The resident was not placed on alert for the
missed Eliquis. The resident's Eliquis order stated to give 2.5mg twice daily for anticoagulant therapy related to the atrial fibrillation diagnosis. ln addition to the missed Eliquis dose, the resident had missed Metoprolol 50mg tablet from 06/27/25 through 07/02/25 when it came back in stock. The resident was not placed on alert for missed doses of Metoprolol. Eliquis and Metoprolol both required a refill script from a primary care provider. Primary care provider had been faxed on 06/24/25, 06/25/25, and 07/02/25 for new scripts. Med tech called on 07/03/25 for a new script of Eliquis to be sent to the community. The resident had Eliquis available in the evening shift medication drawer and was receiving 2.5mg of Eliquis every day on swing shift until 07/06/25, which was the evening shift before being sent out to the hospital.
During an interview with Staff 1 (Executive Director) confirmed that the facility had not made adequate efforts to obtain the resident’s medication. There had been no ISP or alert charting for the missed medication, and no monitoring of potential side effects as a result of missed medication. The facility nurse had not been notified until after the resident was sent to the hospital due to a stroke.
On 07/15/25, at approximately 4:00 pm, the Department requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 07/15/25 at approximately 5:07 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.
The facility failed to monitor a resident’s condition after running out of prescribed medication. The resident missed multiple doses of Eliquis 2.5 mg and Metoprolol 50 mg medications, had a stroke, and was admitted to the hospital on 7/7/2025. The resident was discharged back to the facility on 7/9/2025 and passed away on 7/11/2025.
The facility’s failure to ensure that a resident monitoring and reporting system is implemented 24 hours a day was substantiated.