Health inspection·September 10, 2024

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of (Resident #1) of three residents review for medication changes. Residents Affected - Few The facility failed to obtain written consent from Resident #1's Representative (RP) before administering her Seroquel (for psychosis). This failure could place residents at risk of not having their preferred responsible party represent them in medical and care decisions. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia, depression, anxiety, and delirium (a change in mental abilities). Review of Resident #1's quarterly MDS assessment, dated 09/09/24, reflected a BIMS of 1, indicating a severe cognitive impairment. Section M (Medications) reflected she was receiving an antipsychotic, antidepressant, and hypnotic. Review of Resident #1's quarterly care plan, dated 07/09/24, reflected she had a potential for drug-related complications associated with use of psychotropic medications related to depression, anxiety, and delirium with an intervention of consulting with the pharmacy and MD to consider a dosage reduction when clinically appropriate. Review of Resident #1's Consent for Antipsychotic Medication Treatment, dated 05/10/23, reflected an order for Seroquel - 75 mg/twice daily for amelioration (improvement) of psychosis. The consent form was not signed by her RP. Review of Resident #1's Consent for Antipsychotic Medication Treatment, dated 05/23/24, reflected an order for Seroquel - 100 mg/twice daily for amelioration (improvement) of psychosis. The consent form was not signed by her RP. During an interview on 09/10/24 at 12:52 PM, Resident #1's RP stated she was not notified nor did she give consent to Resident #1 being on Seroquel. She stated she would like to be informed of the Page 1 of 2 455983 455983 09/10/2024 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0552 medication changes so she was involved in the care of Resident #1. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/10/24 at 1:55 PM, the DON stated whenever an order for a psychotropic medication was given for a resident, he expected a consent to be signed by the resident or the resident's RP. He stated it was the SW who normally ensured they were signed. He stated the importance of obtaining a signed consent before administering any psychotropic medications was because it was part of the rules and regulations and it was important to inform family of possible side effects. He stated their policy did not address that a consent was needed, however, it did include the consent attached. He stated he would be addressing this on the corporate level. Residents Affected - Few Review of the facility's Psychotropic Medication Policy, revised 11/2022, reflected the following: Psychotropic medications may be considered for residents but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. 455983 Page 2 of 2