Health inspection·June 2, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a base line care plan that included instructions needed to provide effective and person-centered care of the resident for 1 resident (Resident #117) of 17 residents reviewed for base line care plans. The facility did not develop a base line care plan for Resident #117 that addressed Resident #117's use of antipsychotic medication. This failure could place resident receiving antipsychotic medications of not receiving the necessary care required to maintain psychosocial well-being. The findings were: Record review of Resident #117's Physician's Orders dated 05/30/23 revealed Resident #117 was an [AGE] year-old female who was admitted to the facility on [DATE] with admitting diagnosis of Alzheimer's disease, Type 2 Diabetes Mellitus, and generalized anxiety disorder. Record review of Resident #117's Interim Care Plan (base line care plan) revealed the section for antipsychotics/psychotropics was blank. Record review of Resident #117's Physician's Orders dated 05/30/23 revealed an order for Olanzapine oral tablet 5 mg, give one tablet orally one time a day for anxiety. Record review of Resident#117's e-MAR revealed Resident #117 was administered Olanzapine tablet 5mg on 05/30/23, 05/31/23, and 06/01/23 at 6:30 PM. In an interview on 06/02/23 at 09:45 AM, Resident #117 said she did feel anxiety at times, but she felt well now. Resident said she took her medication. Resident said she only felt anxious when she had a problem and would feel nervous then. Resident said she has not seen her family member in years, and she hoped that her family member was alive. Resident said when she was thinking of her family member, she began to feel nervous. Resident said she did not know if she was taking the medication for anxiety. In an interview on 06/02/23 at 09:57 AM, LVN A said, Resident #117 received the Olanzapine in the evenings. Resident #117 had not had any signs of anxiety. In an Interview on 06/02/23 at 12:37 PM, MDS/LVN B said the Interim Care Plan had to be completed Page 1 of 2 455484 455484 06/02/2023 San Juan Nursing Home Inc 300 N Nebraska San Juan, TX 78589

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few within 24 hours. The admitting nurse was responsible for completing the Interim Care Plan. The nurse would interview the resident or the family if they were available. The MDS/LVN B said the nurse must document all the medications on the Interim Care Plan and would call the physician to see if the resident would continue with the same medications from the hospital. The DON was responsible to review and sign it. In an interview on 06/02/23 at 01:01 PM, LVN C said she had been employed since February 2023. LVN C said when they admit a new resident, they must conduct a full body assessment, check for any injuries to the body, check if the resident had any devices on their body such as an ostomy or g-tube, ask the resident questions about their medical history, ROM, if they have pain, check their neuro status, if they had any diseases, such as cancer. The nurse would do an extensive history, if nothing then they would document that the resident did not have any diseases. The nurse would take their vitals. The nurse would then call the resident's MD and gave a full report and go over the medications and ask if the resident would continue with the same medications. The nurse would also call the RP if the resident had any behaviors and what their medications they are taking. LVN C said, Yes, Resident #117 was taking an antipsychotic, taken once at night. but was unable to remember the name. LVN C said she made a typing error, and the medication should have been checked on the Interim Care Plan. LVN C said if Resident #117 did not get her medication, she might have an episode of psychosis or anxiety and the nurse would have to do research to see what medications resident was taking and if she had been prescribed any antipsychotics and then call the doctor for a script and in the meantime the resident was going through an episode of psychosis or anxiety until they obtained the medication. In an interview on 06/02/23 at 2:30 PM, Assistant Administrator provided a copy of facility's policy for Interim Care Plan (base line care plan). Assistant Administrator said the base line care plan would be done by the admitting nurse. Record review of facility policy revised on 11/08/22 revealed: A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident within twenty-four (24) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within twenty-four (24) hours of the resident's admission. 2. The Interdisciplinary Team will review the Attending Physician's order (e.g., dietary needs, medications, and routine, treatments, etc.), and implement a nursing care plan to meet the resident's immediate care needs. 3. The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. 455484 Page 2 of 2