Fishbone Diagram for Ellie was an 85-year-old resident who was returning to the nursing home on 11/5/2022 from the hospital following a left hip fracture. She had an ORIF done. Prior to her fall, Ellie had been a resident of the nursing home for only a week when she sustained the fracture. She has a history of congestive heart failure with frequent exacerbations. Admission vital signs were BP 132/76, HR 82, RR 18. Ellie's transfer form from the hospital included an order for Lasix as well as a number of new medications. Lasix was part of her original nursing home medication list prior to being transferred to the hospital. All medication orders from the transfer form were re-written on the new Medication Administration Record (MAR), but the old MAR from the previous stay was not removed. When the nurse checked the new orders, she mistakenly interpreted the new Lasix order on the MAR as an unintentional duplication in transcription and yellowed out the line on the MAR. She was interrupted to take a phone call and did not complete the process of checking the new orders. She asked another nurse to complete the process. The second nurse completed double-checking the