Health inspection·September 15, 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, interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 9 (Resident #1) residents reviewed for pharmacy services. The facility failed to only administer medication prescribed by the physician to Resident #1. The noncompliance was identified as PNC. The noncompliance began on 9/05/23 and ended on 9/07/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for adverse reactions. Findings Include: Record review of the face sheet dated 9/15/23 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, cerebral infarction (stroke), myocardial infarction (heart attack), hypertension (high blood pressure), chronic kidney disease, and cognitive communication deficit. Record review of the MDS assessment dated [DATE] indicated Resident #1 was understood by others and understood others. The MDS indicated Resident #1 had a BIMS of 06 and was severely cognitively impaired. Record review of the care plan 7/11/23 indicated Resident #1 was on diuretic (medication that helps your kidneys get rid of extra water in the body) therapy. Record review of the physician orders dated 9/15/23 indicated Resident #1 did not have an order for nebulized Furosemide (a medication converted a liquid to a fine spray, for inhalation of to relieve dyspnea (labored breathing) in patients with COPD and advanced cancer. Record review of a progress note dated 9/05/23 ad 5:12 am written by LVN A indicated, [Resident #1] was nonresponsive, eyes fixed, clammy at 98.4, and gurgling sound in throat. O2 saturation at 70 (how much oxygen if in the bloodstream with normal values being 95-100%), heart rate 121, abdominal breathing, called EMS for transport to hospital. Retrieved crash cart and began to suction resident . Applied O2 [oxygen] via nasal cannula and 4ml Lasix [Furosemide] could be administered via nebulizer. Was able to get O2 [oxygen] saturation to 74% (briefly then turned resident to her left side and suctioned her again, reapplying nebulizer mask. EMS arrived and transported resident to [hospital] . Page 1 of 6 675802 675802 09/15/2023 Kemp Care Center 1351 South Elm Street Kemp, TX 75143

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Medication Error Report dated 9/05/23 indicated LVN A administered nebulized Furosemide to Resident #1 without a physician's order. The Medication Error Report indicated the LVN A's response regarding committing the violation was, I was going to get an order later. I was doing what I knew would help the resident. The Medication Error Report indicated the action taken to correct or prevent reoccurrence was education and in-service of nursing staff and termination of LVN A related to administering medication without a physician's order. Record review of the Medication Error Form dated 9/05/23 indicated medication was administered by LVN A without obtaining an order. The Medication Error Form indicated it was unclear where LVN A obtained the medication from. The Medication Error Form indicated LVN A's response to the violation was, I only did what I knew to be necessary. I figure we would get the order later. The Medication Error Form indicated LVN A had not been previously warned regarding this type of allegation. Record review of the Provider Investigation Report dated 9/07/23 indicated LVN A was terminated on 9/05/23 after LVN A stated she had used nursing judgement and administered nebulized Furosemide without a physician's order to Resident #1 when Resident #1 was unresponsive and had an oxygen saturation in the 70s. The Provider Investigation Report indicated EMS had been called and was enroute to the facility when LVN A administered nebulized Furosemide to Resident #1. The Provider Investigation Report indicated the hospital had informed the DON that Resident #1 had experienced a heart attack and they did not believe there were any adverse effects from the medication error. Record review of the Employer Report Form to the Texas Board of Nursing Regarding Violations indicated the facility filed a report with the Texas Board of Nursing against LVN A for administering nebulized Furosemide to Resident #1 without a physician's order. Record review of Medication Pass Guidelines dated 9/12/23 through 9/15/23 indicated nurses and MAs had been observed for medication cart and drug security, infection control precautions, medication administration, medication, medication refusal, resident assessment, and medication errors by the DON and ADON. The Medication Pass Guidelines indicated all nurses and MAs observed met all of the objectives satisfactorily. During an observation on 9/08/23 at 11:30 a.m., Resident #1 was lying in her hospital bed, intubated, and unresponsive. During an interview on 9/08/23 at 11:33 a.m., the ICU nurse said Resident #1 was admitted to the hospital with a diagnosis of acute respiratory failure hypoxia. During an interview on 9/08/23 at 1:11 p.m., the DON said she did not know where LVN A obtained the nebulized Furosemide that was administered to Resident #1. The DON said there were other resident on the same hall as Resident #1 that had orders for nebulized Furosemide. The DON said LVN A refused to tell her where the medication came from and was terminated for administering medication without an order. The DON said with nebulized Furosemide not being a narcotic there was not a count for the medication that would enable the facility to determine whether or not the medication was taken from another resident. During an interview on 9/14/23 at 8:54 a.m., the DON said she had just got off the phone with the Texas Board of Nursing regarding LVN A. The DON said she had referred LVN A to the Board of Nursing due to administration of nebulized Furosemide to a resident without an order. 675802 Page 2 of 6 675802 09/15/2023 Kemp Care Center 1351 South Elm Street Kemp, TX 75143

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview attempt on 9/14/23 at 9:07 a.m., LVN A did not answer the phone and did not have a voicemail setup. During an interview on 9/14/23 at 12:00 pm, The Administrator said after the medication error incident involving Resident #1 all nurse and med aides were in-serviced regarding medication errors, medication administration, and physician notification. The Administrator said they had an ad hoc QA meeting and the Medical Director was notified. During an interview on 9/14/23 at 12:20 p.m. the DON said LVN A had started at the facility in October 2022. The DON said LVN A had not had any medication errors at the facility until 9/5/23. The DON said LVN A had some one-on-one in-service regarding failing to enter new admission information into the computer. The DON said LVN A worked the night shift. The DON said when she reported LVN A to the Board of Nursing she was informed LVN A had a disciplinary action from the Board of Nursing in 2010, but they did not disclose what it was regarding. The DON said she started at the facility in April 2023 and there had not been any med errors from the time she started until 9/5/23. The DON said she expected the nurses to obtain an order from the physician prior to any medication being administered to a resident. The DON said she expected to be notified immediately of any medication error. During an interview on 9/14/23 at 1:22 p.m., the Medical Director said he was aware of the nebulized Furosemide being administered by LVN A to Resident #1 without an order. The Medical Director said he did not believe the administration of nebulized Furosemide would have been detrimental to Resident #1. The Medical Director said he did not understand the nurse's reasoning for giving the medication. The Medical Director said they had found in pulmonology journals nebulized Furosemide aided in opening the airways in the event of air hunger and hypoxia. The Medical Director said nebulized Furosemide tends to work best with COPD patients. The Medical Director said he would have expected the nurse to have obtained an order for the medication prior to administering it. The Medical Director said that Furosemide given in nebulized form does not act in the same way as when given in pill form or via IV. The Medical Director said Furosemide in nebulized form does not diurese a person it only opens up the airway. The Medical Director said the resident was not at risk for dehydration due to the form the medication was administered in. During an interview on 9/14/23 at 3:53 p.m., The Nurse Practitioner said he was aware of the medication error involving Resident #1. The Nurse Practitioner said administering nebulized Furosemide was not detrimental to Resident #1. The Nurse Practitioner said nebulized Furosemide did not have the diuretic effect oral and IV Furosemide did. The Nurse Practitioner said nebulized Lasix is used to open airways and most often used in heart failure, COPD, or Hospice patients. The Nurse Practitioner said nebulized Furosemide was more of a comfort measure. The Nurse Practitioner said he would have expected the nurse to have obtained an order for a medication before administering it to a resident. During an interview on 9/15/23 at 9:50 a.m., RN B named all rights of medication administration. RN B said staff knew what medications to administer by checking the physician orders. RN B said if a medication was not ordered it should not be given. RN B said an order should always be obtained prior to administering a medication. RN B said the DON should be notified of medication errors, falls, elopements, and new wounds. RN B said if there was a medication error the DON, physician, and resident's family should be notified. RN B said in the event of a medication error a medication error report should be completed. During an interview on 9/15/23 at 10:30 a.m. RN C named the 10 rights of medication administration. RN C said prior to giving a medication, the physician's order should be checked. RN C said a 675802 Page 3 of 6 675802 09/15/2023 Kemp Care Center 1351 South Elm Street Kemp, TX 75143

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication should never be administered that was not ordered by the physician. RN C said administering a medication that was not ordered by the physician would be considered a med error. RN C said medication error should be reported to the DON, physician, and resident's family. RN C said when a med error occurred, a med error form was required to be completed. During an interview on 9/15/23 at 11:13 a.m., MA D was able to name the 10 rights of medication administration. MA D said the physician orders were entered into the MAR and she was required to check the MAR and the medication cards to ensure they matched before giving a medication. MA D said if a resident wanted a medication that was not on her MAR, she would report to the charge nurse and the charge nurse would consult with the physician. MA D said if a medication error occurred she would report it immediately to her charge nurse. During an interview on 9/15/23 at 2:20 p.m., MA E was able to name the 10 rights of medication administration. MA E said the physician orders were entered into the MAR and she was required to check the MAR and the medication cards to ensure they matched before giving a medication. MA E said if a resident wanted a medication that was not on her MAR, she would report to the charge nurse and the charge nurse would consult with the physician. MA E said if a medication error occurred, she would report it immediately to her charge nurse. Record review of the facility's Medication Administration Procedures revised 10/25/17 indicated, .All current medications and dosage schedules are to be listed on the resident's current medication administration record. Medication prescribed for one resident are not to be administered to any other resident. A specific order must be obtained by the physician to change the dosage form of a resident's medication. Medication errors and adverse drug reactions are immediately reported to the resident's physician. In addition, the Director of Nurses and/or designee should be notified. Any medication error will require a medication error report that includes the error and action to prevent reoccurrence .The 10 rights of medication should always be adhered to: 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right patient education 7. Right documentation 8. Right to refuse 9. Right assessment 10. Right evaluation. Record review of facility's undated When to Call the DON policy indicated, It is my expectation that I am called by the charge nurses in the following circumstances. If you are not able to reach me by phone, please send me a text message. If I have not gotten back to you within 10 minutes, please call the ADON .Anytime there is an incident or accident .d. medication errors .Anytime there is a change in condition or new medical concern for a resident .Anytime there is a medication that cannot be located. Anytime there is a discrepancy in a medication count . Record review of the facility's Medication Incident Report Procedure policy dated 2013 indicated, All medication incidents will be documented. Medication administration errors will be reported to the resident's attending physician and family member. The facility staff will take whatever immediate action is necessary to protect the resident's safety and welfare in the event of a medication administration incident. The attending physician and family will be promptly notified of any medication administration incident .Interventions will be put in place to attempt to prevent reoccurrence, i.e., staff education. The facility had corrected the noncompliance by the following: Terminating LVN A immediately 675802 Page 4 of 6 675802 09/15/2023 Kemp Care Center 1351 South Elm Street Kemp, TX 75143

F 0755 Notification to the physician and nurse practitioner Level of Harm - Minimal harm or potential for actual harm In-servicing nurses and medication aides regarding when to call the DON, medication pass, medication rights, and medication errors, medication errors/process, and medication administration. Residents Affected - Few Ad hoc QA meeting regarding the medication error The surveyor confirmed the facility had corrected the non-compliance prior to survey through the following actions: Record review of the Employee Disciplinary Report dated 9/05/23 indicated LVN A was terminated due to failure to adherer to the Corporate Code of Conduct, acting outside of the scope of practice per professional standards of the Texas Board of Nursing, and administering medication without a physician's order. The Employee Disciplinary Report indicated LVN was terminated effective immediately. Record review of a Quality Assurance (QA) Meeting Sign-in Sheet dated 9/06/23 indicated the facility had an ad hoc QA meeting regarding the medication error on 9/05/23. The QA Meeting Sign-in Sheet indicated the physician and nurse practitioner had been notified of the medication error via telephone on 9/05/23. Record review of an in-service dated 9/05/23 indicated nurses, MAs, and CNAs were in-serviced regarding when to call the DON including medication errors, change in condition or new medical concern, any time there is a medication that cannot be located, and anytime there is a discrepancy in a medication count. Record review of an in-service dated 9/05/23 indicated nurses and MAs were in-serviced regarding medication pass, medication rights, and medication errors. Record review of an in-service dated 9/07/23 indicated nurses and MAs were in-serviced regard medication errors/process including ensure resident safety, notify the physician/nurse practitioner, complete any orders/instructions the physician/nurse practitioner had given, notify the DON and Administrator, notify the resident's family/responsible party, complete and event and all required documentation, and monitor the resident. Record review of an in-service dated 9/07/23 indicated all nurses and MAs had been in-serviced regarding medication administration including medications being residents property, nursing staff must follow the 10 right of medication administration (right patient, right medication, right dose, right route, right time, right patient education, right documentation, right to refuse, right assessment, and right evaluation), and any medication error witnessed or suspected must be reported to the DON, Administrator, and physician/nurse practitioner immediately. Interviews were conducted on 9/14/23 between 1:22 p.m. and 3:53 p.m. with the Medical Director and the Nurse Practitioner. The Medical Director and Nurse Practitioner confirmed they had been notified of the nebulized Furosemide being administered by LVN A to Resident #1 without an order. Staff interviewed (RN B, RN C, MA D, and MA E) on 9/15/23 between 9:50 a.m. and 2:20 p.m. were able to answer questions regarding trainings/in-services. The noncompliance was identified as PNC. The noncompliance began on 9/05/23 and ended on 9/07/23. 675802 Page 5 of 6 675802 09/15/2023 Kemp Care Center 1351 South Elm Street Kemp, TX 75143

F 0755 The facility had corrected the noncompliance before the survey began. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675802 Page 6 of 6