Health inspection·May 16, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was given as ordered by the physician. Residents Affected - Few This failure could place residents who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the medication for blood pressure which could result in decreased quality of life. Findings included. Resident #2 Record review of Resident 2#'s admission face sheet dated 05/15/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses diagnosis included essential hypertension (high blood pressure). Record review of Resident#2's MDS dated [DATE] revealed a BIMS score of 08, indicating Resident #2's cognitive skills for decision making was moderately impaired. Record review of Resident #2's physician's order summary report for May 2024 revealed an order dated 5/6/2024 for Metoprolol Tartrate Oral Tablet 25mg give 1 tablet by mouth every 12 hours for Hypertension. Hold for SBP <110 or DBP< 70 or HR < 60. Record review of Resident #2's MARs revealed Metoprolol Tartrate Oral Tablet 25mg the medication was administered on the following date and time: * 5/07/2024 at 9:00pm when the blood pressure was 83/51, on *5/09/2024 at 9:00 PM when SBP was 105/67, and on *5/10/2024 at 9:00 PM when SBP was 105/67. Further record review of the MARs revealed on 05/09/2024 and 05/10/2024 were given by LVN C. In an observation and interview on 05/15/2024 at 10 :55 Resident #2 was observed in bed. She was alert and oriented and could make their needs known. She was clean and well-groomed with no offensive odor. Resident was able to voice her needs. Interview with Resident #2 revealed she had no problems getting her medications. Page 1 of 2 675233 675233 05/16/2024 Harmony Care at Golfcrest 6150 S Loop East Houston, TX 77087

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 5/16/2024 at 10:00am with LVN C, she said she was not the one who gave Resident #2 her 9:00pm medication. She said she usually checked the resident blood pressure before her medication was administered. She said if her blood pressure was in the parameter that it should be held, she would not give it. She said she would hold the blood pressure medication. She said she it was difficult to say when the medication was held and when it was documented as given. She said if medications were not given it should be documented as not given and the reason why it was not given. In an interview on 05/15/2024 at 3:00pm the DON said her expectations was the orders were followed and when the vital signs were within the parameters the medications should not be given. She said she was going to in-service the staff and supervise the blood pressure medication administration. In an interview on 5/16/2024 at 3:20pm with LVN B she said she was sure she held the medications because she knew that Resident #2's blood pressure sometimes ran low. She said she might have documented incorrectly. She said that if the blood was already low and she gave the medication it would bring the blood pressure lower, and this would cause the resident to get dizzy and could get sick. Further interview with the DON on 5/16/2024 at 3:45pm she said Resident #2's blood pressure could drop when the medication that was to be held was given. That could cause her to become dizzy and fall and injury could occur. The DON said Resident #2's blood pressure medication has parameters and once the blood pressure was checked, and the blood pressure was in the parameter if it was ordered to be held, then they should not have given the medication. She said she was going to in-service the staff regarding blood pressure parameters, and she was going to audit blood pressure medication to ensure they have parameters in place, and staff were following the parameters. In an interview on 5/16/2024 at 4:00pm, the Administrator stated the expectations were that medications were given according to the physician's orders. He said he would have to ensure that staff were in-serviced. Record review of the facility policy titled Administering Oral Medication undated read in part . Purpose: To provide guidelines for safe administration of oral medications. Preparation. Verify that there is a physician's order for this procedure. Steps in the Procedure . 13. Perform any pre-administration assessment Medications are prepared, administered, and recorded by the same authorized medical/licensed staff. Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration . 675233 Page 2 of 2