Health inspection·November 17, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 resident (Residents #1) out of 8 residents reviewed for medication administration in that: The facility failed to ensure Resident #1 was administered medications according to physician parameters. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications, could result in a worsening or exacerbation of chronic medical conditions, hospitalization and or a diminished quality of life. The findings include: Record review of the admission Record revealed Resident #1 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #1's primary medical condition for admission was amputation of two or more right lesser toes. Other active diagnoses included: Hypertension [high blood pressure] and dependence on hemodialysis [mechanical process in which waste and excess fluids are filtered from the blood when the kidneys are no longer adequately able to function]. Resident #1 had a summary BIMS score of 10, indicative of moderate cognitive impairment. Record review of the Order Details printed 11/17/2023 at 11:39 AM, revealed Resident #1 had physician orders for Midodrine [a medication used to elevate low blood pressure] 10 milligrams by mouth three times a day with a start date of 8/17/2023 including parameters to hold if systolic blood pressure was greater than 110 or diastolic blood pressure was greater than 70. Record review of the Care Plan revealed Resident #1 had a problem area of impaired tissue perfusion related to hypotension; with the following associated interventions: give medications as ordered, initiated on 9/8/2023. ? Record review of Medication Administration Record, printed 11/17/2023 at 11:28 AM, revealed Page 1 of 3 675395 675395 11/17/2023 Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840

F 0755 Resident #1 was administered Midodrine, outside of physician parameters in the following instances: Level of Harm - Minimal harm or potential for actual harm -8/19/2023 at 1:00 PM when the blood pressure was 130/72 by MA B; -8/19/2023 at 8:00 PM when the blood pressure was 132/68 by LVN E; Residents Affected - Few -8/20/2023 at 1:00 PM when the blood pressure was 130/72 by nurse MA B; -8/20/2023 at 8:00 PM when the blood pressure was 127/71 by nurse MA C; -8/21/2023 at 8:00 PM when the blood pressure was 136/74 by nurse MA C; -8/22/2023 at 5:00 AM when the blood pressure was 120/55 by an unidentified staff; -8/23/2023 at 1:00 PM when the blood pressure was 139/70 by nurse MA A; -8/24/2023 at 5:00 AM when the blood pressure was 122/56 by an unidentified staff; -8/26/2023 at 5:00 AM when the blood pressure was 120/61 by nurse LVN G; -8/26/2023 at 8:00 PM when the blood pressure was 113 / 68 by nurse MA C; and -8/27/20/23 at 5:00 AM when the blood pressure was 130 / 80 by nurse RN H. In an interview on 11/17/2023 at 5:45 PM, LVN I stated that midodrine was a medication administered for low blood pressure, usually given to dialysis patients because their blood pressure tends to run low before dialysis. LVN I stated blood pressure and heart rate would need to be checked prior to administering midodrine. LVN I stated that the medication should not be given if it was above a certain range, as dictated by the physician or pharmacist. LVN I stated the MAR showed the order with an alert to enter the blood pressure or heart rate. LVN I could not recall if she had provided care to Resident #1 but was aware she left the facility from dialysis unexpectedly and against medical advice. In an interview on 11/17/2023 at 7:00 PM, the DON stated she spot checks MARs for missing documentation or omitted medications. The DON stated she was not aware midodrine was administered outside of parameters for Resident #1 in August 2023. The DON stated the expectation was for staff administering medications to follow the physician orders as written. The DON stated this was covered in new hire on-boarding, annual competencies and PRN In-Servicing. the DON stated, anything could have happened if medications are administered out of parameters. The DON stated midodrine was usually given to residents receiving hemodialysis, to elevate a low blood pressure and should not be given when the blood pressure is above the parameters as determined by the physician. Review of Lippincott procedures, Oral Drug Administration, revised 5/19/2022, accessed 11/27/2023, from: https://procedures.lww.com/lnp/view.do?pId=4420477, revealed, under the subheading Special Considerations, Assess parameters, such as blood pressure and pulse, as necessary before administering a medication with dose-holding parameters. Review of Medication Administration Policy and Procedure Manual revised 10/01/2019, revealed under the heading Procedure, in step 9.) Right Assessment .medications like blood pressure medications 675395 Page 2 of 3 675395 11/17/2023 Val Verde Nursing and Rehabilitation Center 100 Hermann Dr Del Rio, TX 78840

F 0755 always warrant a quick blood pressure check before giving a blood pressure medication. Nurses must be aware of parameters for administration specific to a medication. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675395 Page 3 of 3