Health inspection·March 12, 2024

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 observations, interviews, and record review, 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 of 5 residents reviewed for medications (Resident #1). 1)The facility failed to ensure Resident #1 did not receive another resident's medication during her medication pass. These failures could place residents at risk of experiencing side effect of medications which could result in the exacerbation of their medical conditions and a decline in health status. The findings included: Resident #1 Record review of the face sheet, dated 03/12/24, for Resident #1 revealed that the resident was admitted to the facility on [DATE]. The resident was a [AGE] year old female and had diagnoses of retroperitoneal hematoma (bleeding in the abdominal area) and type 2 diabetes. Record review of the admission MDS assessment dated [DATE] revealed that Resident #1 had a BIMS score of 15 indicating that the resident was cognitively intact. Record Review of Resident #1's MAR dated from 03/01/24-03/18/24 revealed that her blood sugar was monitored 4 times daily. No blood sugar documentation reflected over 250 or lower than 90. (70-125= Normal) Record review of Resident #1's Order Summary dated 03/12/24, revealed that she did not have an order for metformin, protonix, Plavix, tizanidine or colace (docusate). Record review of Resident #1 progress notes revealed the following: On 03/06/24 at 7:05 PM Resident #1's family member called the nurse and notified the DON that Resident #1 had drank water out of a cup that had medications in the bottom of it. The DON went to Resident #1 and was shown a picture of the cup. The DON investigated the incident and found that the medications in the cup were metformin, protonix, Plavix, docusate and tizanidine. The DON reported the medications to Resident #1 and they (DON and staff) would monitor for negative outcomes. The FNP was Page 1 of 4 675842 675842 03/12/2024 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0755 notified of the incident. The FNP did not issue any new orders. No negative outcomes identified. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/08/24 at 4:35 PM, the Family Member revealed that she had received a call from Resident #1 stating that she had received another resident's medications. She said Resident #1 told her that she noticed the water was murky but did not think anything of it. She said she was told by Resident #1 that she noticed it after drinking the water. She said she was told that there were 5-6 pills in the cup. She said Resident #1 told her that she notified the staff and that the staff member who administered the medications was reprimanded in front of her. Residents Affected - Few During an interview on 03/08/24 at 5:10 PM, Resident #1 revealed on 03/06/24, a staff of an unknown name gave her a clear cup that looked like water. She said she looked in the small medication cup and checked her pills to ensure that her medications were correct. She said she noticed something at the bottom of the cup after she drank the water. She said she took a picture of the cup with the pills in it. She called the staff back in and said, Ma'am, these medications are not mine. She said the staff responded to her and said, Uhh ok, and this had never happened before. She said she walked out and then walked back in with another lady who proceeded to reprimand the staff that had given her the medication. She said the other lady (unknown) asked the lady who had given her the medication if she had watched her take medication and said that she was not supposed to leave until she had taken all of her medications. She then asked the DON for a list of the medications in the water cup. She said the DON provided her with a list on a pink sticky note. She said she did not feel any different but that her family member was upset. She said she could not confirm if she had swallowed any pills from the cup. On 03/08/24 at 5:10 PM, an observation was made of a pink sticky note undated with the following written: Metformin, protonix, Plavix, tizanidine and colace. On 03/08/24 at 5:15 PM, an observation was made of a picture on Resident #1's phone dated 03/06/24 at 4:24 PM of a photograph of 5 unknown pills in a cup. During an interview on 03/12/24 at 10:30 AM, the DON revealed it was her understanding that on 03/06/24, CMA A was prepping another resident's medication and was called away. CMA forgot the pills were in the cup. When CMA A went to give Resident #1 her medications, CMA A poured the water over the other resident's pills and gave the water with the pills in it to Resident #1. She said they completed the medication error form, notified the FNP, and monitored for adverse reactions because of the incident. She said there were no adverse reactions. She said the medications in the cup were not all the way dissolved. She said she was able to figure out the other resident and what the medications were because of the metformin. She said metformin has a distinct shape, and not many residents in the facility are on metformin. Once she was able to narrow down who took metformin, she was able to identify the other pills. She said the potential negative outcome for Resident #1 receiving medications that were not hers was that the metformin could have dropped her blood sugar but that she was not having symptoms. She said if the blood sugar gets low enough, a resident could go into a coma. She said she did not have a system to monitor because she did not know how to address it. She did not know why CMA A popped the medications into the water cup. She said she expected the staff to use the medication cup for medications and the water cups for water. She said the medication Aide was responsible for ensuring that the residents in the facility receive the correct medications and that they do not receive other residents' medications. During an interview on 03/12/24 at 2:07 PM, the FNP revealed she was notified on 03/06/24 about the medication error with Resident #1. She said she was told that CMA A had mistakenly given Resident 675842 Page 2 of 4 675842 03/12/2024 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #1 water for medication with another resident's medication in it. She said when she was notified, she instructed staff to monitor because she was told that the pills had not completely dissolved and that there was still pill residue in the cup. She said that after being told what medications had been identified, she was not concerned. She said Resident #1 was able to voice her needs, but nothing was expressed. She said that all residents were expected to receive their mediations, not those of other residents. She said the potential negative outcome of Resident #1 receiving the medications of another resident specifically was that the colace could have caused her to have loose stools. The tizanidine could have caused drowsiness. She said there was no risk with the Protonix. She said the metformin could have caused low blood sugar, but there was no genuine concern because Resident #1 also has a diagnosis of diabetes, and her blood sugar was monitored regularly. She said even with the dissolving of the medications, one dose of any of the identified medications would not have caused concern. During an interview on 03/12/24 at 2:21 PM, CMA A revealed on 03/06.24, she was in the middle of a medication pass when the ADM asked about the call lights going off. She said the certified nurse's aide assigned to the floor was unavailable. She said that she felt obligated to assist because the ADM asked about the call light. She said she gave Resident #1 another resident's medications before she knew it. She said she could not remember who their medications were. She said she felt the reason this happened was because she stopped in the middle of her medication pass. She said she had popped 4-5 pills. She said she apologized to Resident #1 for her mistake. She said she checked on Resident #1 three times after the incident to ensure that she was ok. She said Resident #1 did not display any issues. She said she took responsibility for giving Resident #1 another resident's medication in her water, and did not know what was going on with her that day. She said she thought she may have been in trouble for not answering the call lights, and that was where her focus was. She said she was unaware that she was pouring water into the cup that had the medication in it. She said the system she used was to slow down and concentrate and that she had not followed that system on 03/06/24. She said she had a lot of training. She said the potential negative outcome was that, in the worst-case scenario, she could have been killed or allergic. She said she was thankful that it was not that serious. She said that she had been under a lot of stress, but she had not told anyone that she was under stress. During an interview on 03/18/24 at 4:23 PM, the ADM revealed that she was unsure when Resident #1 received another resident's medications in her water from CMA A. She said Resident #1 told her about it. She said Resident #1 hit her call light, and she responded to it. She said she asked Resident #1 if she swallowed the pills, and she was told that she did not think she did but that she drank the water. She said Resident #1 showed her a picture of the pills in the cup. She said CMA A gave her the cup of water with the pills in it. She said she expected that CMA A should have given Resident #1 her medications without another resident's medications. She said the medication cups should be used for medications, and water cups should be used for water. She said the potential negative outcome could have been that Resident #1 could have swallowed another resident's medications. She said she was unaware that CMA A had given Resident #1 another resident's medication in her drinking water. She said CMA A had been trained to administer medications. She said CMA A, DON, and nursing staff were responsible for administering the correct medications. She said she believed the reason CMA A made the mistake of giving Resident #1 another resident's medication was because CMA A lost her train of thought. Record review of the facility medication error report dated 03/06/24 revealed that at 4:00 PM, Resident #1 received a cup with pills that were not hers. The report identified CMA A as the person who 675842 Page 3 of 4 675842 03/12/2024 MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few made the error. The report identified Resident #1 as the person who identified the error. The error was described as the wrong medication and the wrong resident. The reason noted was failure to look in the cup before putting water in it. The report did not identify any adverse reactions. Record review of the facility policy, titled Pharmacy Services, Overview, Revised April 2019, revealed the following documentation, Policy Statement. The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication, and biologicals, and the services of a licensed pharmacist. Policy Interpretation and Implementation. 675842 Page 4 of 4