Health inspection·June 9, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 MDS data was transmitted within 14 days of completion for 1 of 10 residents (CR #4), in that: Residents Affected - Few CR #4's discharge assessment was never completed and submitted following discharge on [DATE]. This failure could place residents at risk for receiving unnecessary services or inadequate care. Finding included: Record review of CR #4's face sheet, printed 6/8/2023 revealed an [AGE] year-old female who was admitted on [DATE] and discharged [DATE]. Record review of CR #4's MDS section I, dated revealed the resident had diagnoses including osteoporosis and hypertension. Record review of CR #4's MDS, dated [DATE], revealed the resident MDS OBRA assessment completed but not a discharge assessment. In an interview with the MDS Coordinator on 06/09/2023 at 7:11AM, the MDS Coordinator stated CR #4 was only in the facility for 5 days and on the 5th day, she completed the OBRA and admission assessment but forgot to check off that she discharged . She also stated per policy of the RAI manual, the rule was to transmit completed assessments within 14 days. The MDS Coordinator stated she did not know what the implications were because this was the first this had happened to her. In an interview with the Program Director on 06/09/23 at 09:57AM, she stated she monitors information she receives from feedback reports, and provider reports and 5-star reports provided by CMS. She stated there was not necessarily a report to see missed MDS assessments. She also said she was not too familiar with all the types of MDS assessments, but in this case believes the MDS Coordinator made an honest mistake but had corrected the issue today. Record review of the RAI Manual, revised October 2019, stated, . Short-term or respite residents: An RAI must be completed for any individual residing more than 14 days on a unit of a facility that is certified as a long-term care facility for participation in the Medicare or Medicaid programs. If the respite resident is in a certified bed, the OBRA assessment schedule and tracking document Page 1 of 5 675370 675370 06/09/2023 The Methodist Hospital Snf 6565 Fannin Houston, TX 77030

F 0640 requirements must be followed. If the respite resident is in the facility for fewer than 14 days, an OBRA admission assessment is not required; however, an OBRA Discharge assessment is required. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675370 Page 2 of 5 675370 06/09/2023 The Methodist Hospital Snf 6565 Fannin Houston, TX 77030

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 30 opportunities, which involved 1 of 4 residents (Resident #7) and 1 of 3 staff (RN A) reviewed for medication errors in that: Residents Affected - Few -RN A failed to administer Resident #7's medications via G-Tube ( A tube inserted into the abdomen directly into the stomach to provide nutrition, liquid and medications) individually and failed to administer a water flush between each medication. These failures could place residents who receive medications via gastrostomy tube by placing them at risk of inadequate therapeutic outcomes and a decline in health. Findings included: Record review of Resident #7's admission face sheet dated 05/15/2023 revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: malignant neoplasms (cancer) of the tongue, head, neck and face, respiratory failure (lungs cannot get enough oxygen into the blood), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), chronic heart failure, and G-Tube. Record review of Resident #7's admission MDS dated [DATE] revealed in part: Resident #7's speech clarity the resident was absent of spoken words. The resident's BIMS was 14 to indicate he was cognitively intact. Resident # 7 was totally dependent by one staff for eating. The resident's active diagnoses were medically complex to include cancer, heart failure, tracheostomy. Record review of Resident #7's care plan dated 05/27/2023 revealed in part: Focus: Nutrition; Goal: To achieve/improve and maintain an adequate nutritional status; to administer tube feeding safely; to administer medications without complications; Interventions: If more than one medication was being administered, flush with 10ml of water between each medication. Record review of Resident #7's physician's order report dated June 2023 revealed the following orders: Multiple vitamin one tablet by feeding tube daily, order start date 05/16/2023; Entresto 24-26Mg (medication to treat chronic heart failure) one tablet by feeding tube two times daily, order start date 05/17/2023; Plavix 75 Mg (medication to prevent blood platelets from clumping together to form clots) one tablet by feeding tubes daily, order start date 05/24/2023. 675370 Page 3 of 5 675370 06/09/2023 The Methodist Hospital Snf 6565 Fannin Houston, TX 77030

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the unit training titled Feeding Tubes: Nasoenteral (Tube inserted through the nose to the stomach to administer medications, nutrition) , Gastrostomy and Small Bowel, dated 02/06/2023 read in part: Administer each medication separately, flush the tube after each medication administered with 30ml of water. In an observation on 06/07/2023 at 11:51 AM, Resident # 7 was sitting up in bed awake, alert and nonverbal. RN A checked Resident # 7's blood pressure which was 115/54. RN A returned to the medication cart. RN A placed the resident's multiple vitamin, entrestro and Plavix in the pill crusher. RN A crushed the three tablets together. RN A added the crushed medications to a cup with 280 ml of water. The three mediations were dissolved in the cup of water. RN A returned to the resident. RN A checked Resident #7's stomach residual (purpose of checking stomach residual was to check the amount of liquid in the stomach prior to medications and feedings). RN A flushed Resident #7's G-Tube with 15ml water. RN A added the three dissolved mediations in to a 60 ml syringe. The mediations were administered by gravity flow into the G-Tube. RN A administered all three medications at one time. In an interview on 06/07/2023 at 12:05 PM immediately after the medication administration RN A stated she did mix Resident #7s multiple vitamin, Plavix and entrestro together. RN A stated this was how she gave the resident his medications. RN A stated she administered the medications this way to prevent the G-Tube form clogging. In a follow up interview on 06/07/2023 at 1:15 PM RN A stated she did crush resident #7's Multiple vitamin, Plavix and entrestro together. RN A stated she put them together in one cup of water to dissolve the medications. The RN stated she wanted to prevent the resident's G-Tube from clogging. RN A stated each medication should have been crushed separate. She continued and stated she should have flushed after each medication with water. RN A stated the risk of not separating the medication was the possibility of an interaction between the medications. In an interview on 06/08/2023 at 12:22 PM, the Unit Manager stated her expectations were G-Tube medications were crushed and administered separately. The Unit Manager stated each medication was to be separated with a water flush. The Unit Manager stated each mediation was to be crushed separate then dissolved in water. She continued and stated G-Tube crushed medications were not to be administered together. The Unit Manager stated one risk of the medications administered together was a possible interaction between medications. The Unit Manager stated another risk was if the tube clogged during administration the nurse would not be able to determine which mediation had been administered. The Unit Manager stated to prevent this from occurring again all staff would be in serviced on G-Tube medication administration. The Unit Manager stated the nurse who administered the medication would be in serviced one on one. In an interview on 06/08/223 at 2:12 PM, the Director stated her expectations for G-Tube medications were crushed and administered separately. The Director stated each medication was dissolved in water. She continued and stated a water flush was to be given between each medication. The Director stated a risk of combining the mediations were compatibility. The Director stated another risk of combining the medication was not knowing what or how much of a medication was administered if the tube became clogged. The Director stated the plan to prevent this from occurring again was staff education. The Director stated the monitoring of medication administration was done by the Hospital Pharmacy Technician. The Director stated the Hospital Pharmacy Technician monitors medication administration. The Directory stated the Hospital Pharmacy Technician audited the staff by observing mediation administration monthly. 675370 Page 4 of 5 675370 06/09/2023 The Methodist Hospital Snf 6565 Fannin Houston, TX 77030

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 06/09/2023 at 8:17 AM, the Hospital Pharmacy Technician stated she did monthly observations of medication administration to audit the staff's medication administration. The Pharmacy Technician stated she had not had any issues with her observation. The Pharmacy Technician stated she had not done any recent G-Tube administration observation. The Pharmacy Technician stated she followed the nurse and what medication that was scheduled. The Pharmacy Technician stated the correct way to administer the G-tube mediations was separately with a water flush between each medication to prevent them from mixing together. The Pharmacy technician stated if she observed a problem during her audits, she notified the Unit Manager for additional education. Record review of the policy titled Feeding Tube: Medication Administration dated February 2023 read in part .22. Administer liquid or dissolved medications by pouring it into the syringe and flush. A. After the administration of medications or formula, clear the tube by flushing it with a minimum of 15 ml of purified water . 675370 Page 5 of 5