Health inspection·February 1, 2024

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services to include procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 (CR#1) residents reviewed for pharmacy services to meet the needs of each resident in that: 1. The facility failed to ensure physician ordered, Tramadol (an FDA controlled medication for pain) was provided the scheduled or PRN as resident requested for her pain; 2. The facility failed to ensure Nifedipine hypertension medication was provided to CR#1 causing a high systolic pressure and hospital admission. This failure caused CR#1 to have unresolved pain and an increase in her BP and placed all residents in the facility at risk for missed medications. Findings Included: Record review of CR#1's undated face sheet revealed an [AGE] year-old woman who was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (a general term for a group of thinking and social symptoms that interferes with daily functioning), Hyperlipidemia (a condition in which rthere are high levels of fat particle in the blood) , Hypertensive heart disease(changes in the left ventricle, left atrium as a result of chronic blood pressure elevation) with heart failure and low back pain. Record review of CR#1's MDS dated [DATE] revealed Section C500- Brief interview of mental status (BIMS) score was 13, which meant she was cognitively intact. Record review of CR #1's physician orders dated 1/23/2023 revealed Tramadol HCL oral tablet 100 mg every 12 hours as needed for pain and twice PRN and Nifedipine Oral capsule 10 mg by mouth at bedtime for HTN (hypertension) hold for SBP (systolic blood pressure) <100. Record review of CR#1's MAR dated 1/1/2024-1/31/2024 record revealed no one documented that Tramadol HCL 100 mg oral tablet was given on 1/15, or 1/18 on night shift. Further review revealed Nifedipine 10 mgs was not documented as given on 1/9, 1/15 or 1/18/2024. Page 1 of 3 675848 675848 02/01/2024 Focused Care at Webster 17231 Mill Forest Webster, TX 77598

F 0755 1/9/2024- Blood pressure shows N/A in documentation. Level of Harm - Actual harm 1/15/2024 - Blood pressure was documented as 134/78. It should have been given Residents Affected - Some 1/18/2024- Blood pressure was documented as 120/71 .It should have been given. Record review of Disciplinary action record revealed DON wrote a written action notice for LVN A on 1/23/2024. Dates of occurrences were 1/15/2024 and 1/18/2024. Facts regarding incident: LVN A failed to administer scheduled medication to CR#1. LVN A failed to document why medication was not given. Expectations for team member behavior: LVN A will administer resident medications as ordered when unable to she will document accordingly. An interview with CR#1's RP on 1/30/2024 at 2:45 p.m. revealed CR#1 had been admitted to the hospital on [DATE] due to her blood pressure being elevated to 200/67. She said she learned that LVN A had not been administering CR#1's pain or high blood pressure medications. She said she learned about CR#1's missed medications on or about 1/18/2024 when she received a call from an unnamed Nurse. She said she was not sure of the exact date she received the call. She said the doctor decided to send her to the hospital because CR#1's blood pressure was high. She was discharged to the hospital on 1/19/2024 and will not return to the facility. She said was not aware of the exact days CR#1 missed her medications. An interview with Regional Operations Manager on 1/30/2024 at 3:07pm, revealed she stated LVN A failed to ensure CR#1 received her pain or hypertension medications. She could not recall which medication was not administered at the time. She stated she was out of the building and received a call from a former nurse (RN A) who stated she ran a missed medication report and learned that LVN A did not administer medications. She said RN A said told the DON and she instructed the DON to do a written warning of discipline. She said the Regional Nurse had remote access and reviewed the MAR and LVN A had put see progress note by the reason the medication was not given. She stated again that she did not recall which medications but recalled that it was 2 days. She said that LVN A had been educated on Neglect by the DON. She said the physician had been notified. An interview with the DON on 1/30/2024 at 3:21pm revealed she wrote the written disciplinary action for LVN A . She stated former nurse (RN A) ran a missed medication report and verified that LVN A had not given CR#1 her hypertension medication on 1/15/2024 and 1/18/2024. She said it was her understanding on the evening of 1/15/2024 CR#1 had visitors in her room and did not want her pain medication at the time. She said she is not sure what exactly happened. But, LVN A did not document that she had given her the pain or hypertension medication. She said she looked at the schedule and LVN A worked both nights she was supposed to get the night dose of Nifedipine or the scheduled Tramadol. She said her expectation is that all medications will be administered as ordered, document any refusals and notify the physician. She said the physician and family were notified. An interview with the Administrator on 2/1/2024 at 9:23am, revealed she had been employed two days at the facility. She said she wanted to learn more information and called LVN A to interview about the incident. She said LVN A stated CR#1 was in a bad mood on 1/18/2024 and refused her Tramadol although she was complaining about being in pain. She said she questioned why a resident in pain would refuse her pain medication. She said LVN A said CR#1 did not want it on or about 10pm but she later gave CR#1 the medication. She said she was confused about this situation. She said she spoke with two CNA's that said the Resident was agitated. She said she was still looking into the incident. 675848 Page 2 of 3 675848 02/01/2024 Focused Care at Webster 17231 Mill Forest Webster, TX 77598

F 0755 Level of Harm - Actual harm Residents Affected - Some An interview with LVN A on 2/1/24 at 11:15am, states she and CR#1 had a good relationship. She said she attempted to give her medications 1/18/2024/around 10pm but she did not want her melatonin until she had taken her shower. She said Melatonin and all her medications were provided on the 15th and 18th. She said CR#1 had no issues taking her blood pressure medication and her blood pressure was in normal range. LVN A stated CR#1 refused a PRN medication (tramadol) on the 19th around 4 a.m. after complaining of pain . She said the resident got angry saying that she should have offered the medication earlier in the night and she used expletives towards her. She explained that it is a PRN medication, and she has to tell her she needed it for her pain. CR #1 was screaming down the hallway. Aides in room with her. LVN A said she did not pop the medication. It was her understanding that CR#1 told the DON said she had not given CR#1 her medications. She said denied CR#1 used expletives prior to this incident. She said it is her job to provide medications as ordered. She said on the night of 2/18/2024 the computer was glitching and this might be why her documentation was not there, but she did administer all medications as ordered. An interview with CR#1 on 2/1/2024 at 3:30 p.m. revealed LVN A did not give her Tramadol like she requested on 1/15, 1/18 and a night prior but she could not recall the date. She said she requested her Tramadol later during the night when she was ready to sleep due to her back pain. She said she was currently at a local hospital and had a pacemaker put in earlier today (2/1/2024). She said she had no issues getting her medications except the last few days before she left the facility. CR#1 said she was not sure why those nights were a problem for LVN A to give her medications as she requested. She said she never denied her blood pressure or pain medication. She would sometimes ask LVN A to come back to give her the Tramadol. Record review of the medication and orders policy revised 7/2016 did not address missed medications or documentation requirements. 675848 Page 3 of 3