Health inspection·January 25, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 (Resident #3) residents reviewed for medication administration. Residents Affected - Some Resident #3 did not receive a Fentanyl transdermal (pain medicine delivered through the skin) patch every three days as ordered by her physician. The failure was identified as past non-compliance as the facility had instituted adequate corrective measures to prevent reoccurrence of the non-compliance. The facility's failure to administer medications correctly could affect all residents resulting in exacerbation of their condition resulting in complications from deterioration in health, extended recoveries, hospitalizations, and death. Findings include: Record review of Resident #3's clinical record revealed a [AGE] year old female, admitted on [DATE], with the following diagnoses: Chronic Obstructive Pulmonary Disease, chronic pain, vitamin D deficiency, type 2 Diabetes, major depressive disorder, anxiety disorder, morbid obesity, hyperlipidemia, myocardial infarction, congestive heart failure, peripheral vascular disease, chronic respiratory failure, complete traumatic amputation at left knee level, protein-calorie malnutrition. -Record review of a quarterly MDS, dated [DATE], documented the resident scored 15 of 15 on a mini-mental exam for cognitive awareness, required extensive assistance by two staff for bed mobility, transfers, dressing, toileting and bathing, incontinent, 60 inches tall and 216 pounds. -Record review of Resident #3's admission orders, dated 10/30/23, from the physician documented the following order: Fentanyl Transdermal Patch 72 hour 12 MCG/HR - Apply 1 patch transdermally one time a day every three days for chronic pain. -Record review of the MARs for Resident #3 for 10/30/23: Fentanyl Transdermal Patch 72 hour 12 MCG/HR - Apply 1 patch transdermally one time a day every three days for chronic pain (Start date 10/30/23), indicated the following: -October 2023: The patch for 10/30/23 was documented as code 5 - On hold and not given Page 1 of 4 675851 675851 01/25/2024 Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

F 0760 -November 2023: Level of Harm - Minimal harm or potential for actual harm November 3, 6, 9, 12, 15, 18, 21, 24 and 30, the patch was documented as other and not administered. November 27 was documented as Code 5 - On hold and not administered. Residents Affected - Some -December 2023: December 3, 6, 9, 12, 15, 18, 21, 24, 27 and 30, the patch was documented as other and not administered. -January 2024: January 2 - the patch was documented as other and not administered January 3 (when the missing medication was brought to the attention of the ADON) Resident #3 was administered a Fentanyl patch at 10:32 p.m. During an interview on 1/25/24 at 8:45 a.m., Resident #3 stated since she was getting the Fentanyl patch, her pain was so much more controllable. Resident #3 did not know if there was a concern about her patch not being ordered timely because she has always had her pain covered. Resident #3 stated she had her left leg amputated above the knee last September and she was having a lot of phantom pain and it would really hurt sometimes. During an interview on 1/25/24/at 1:50 p.m., the ADON stated she was coming into the building on 1/3/24 around 6:00 a.m. and was notified about Resident #3's missing Fentanyl patches. The ADON stated the night nurse was asking why Resident #3's medication was not in the facility as it was ordered on October 30th, the day she was admitted . The ADON stated she immediately notified the Administrator, DON and the Regional Nurse. The ADON stated she contacted the pharmacy and got the Fentanyl patches that day and Resident #3 was administered the Fentanyl patch that evening. The ADON stated the Fentanyl patch was on the MAR but the nurses were documenting that the Fentanyl patch was on order from the pharmacy when the nurses should have called the pharmacy to see where the medication was but the nurses did not do that. The ADON stated the triplicate for the Fentanyl patch was sent to the pharmacy on October 30th but none of the nurses bothered to follow up on the missing medication. The ADON stated the triplicate order was sent to the pharmacy but was not signed so the pharmacy did not fill it and did not contact the facility to get it signed nor did the nurses follow up on the patches. The ADON was so surprised that the nurses did not call her if the medication was missing because they even call her for eye drops if they are not in the medication cart. During an interview on 1/25/24 at 2:00 p.m., the Administrator stated the nurses should have called the pharmacy when the Fentanyl patch was not available instead of documenting that the medication was not available instead of documenting that the medication was ordered. The Administrator stated there was a glitch in the computer system that did not show the medication as missing but that was fixed now to where the missing medication would show up on the 24 hours reported. The Administrator stated she pulls the Medication Audit report on a daily basis and it will tell her if a nurse puts on the MAR that a medication was not available so she could double check with the nurse about what was going on with that mediation. The Administrator stated what should have happened was the nurse should have called the pharmacy and then notified the DON or ADON that the mediation was not in the 675851 Page 2 of 4 675851 01/25/2024 Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some building. The Administrator stated they went over everyone's medications after the incident with the missing Fentanyl patches and no one else was missing any medications. The Administrator stated every nurse in the facility received a one on one coaching for making sure medications arrived to the facility after they have been ordered. During an interview on 1/25/24 at 2:25 p.m., the DON stated Resident #3 was assessed for pain on a daily basis and all other residents were assessed three times a week to ensure everyone's pain was being addressed. During a telephone interview on 1/25/24 at 2:35 p.m., LVN A stated she relieved the night nurse on 1/3/24 and was informed that Resident #3's Fentanyl patch was not in the medication cart and she needed to pass that on to the DON or ADON. LVN A stated she reported the missing Fentanyl patches to the ADON and she said she would look into it. LVN A stated she could not figure out why the Fentanyl patch was not ordered when Resident #3 was admitted to the facility. LVN A stated she had mentioned the missing Fentanyl to the DON on several occasions but the medication still did not come in. Record review of the policy titled, Medication Administration Procedures, revised 10/25/17, does not state the process to follow if a medication is not available for Resident use, no other policy provided. Record review of the Inservice Training Report, dated 1/3/24 and prior to this investigation, documented the following: Subject: Medication Administration Policy/Medication Not Available Protocols Summary of Subject: Medication administration and medication isn't available. When receiving a medication, you must sign in the medication in the computer and put the medication slip in the medication room in binder. DO not put the slip in ADON or DON box. It medication ins not on hand, CMA must let the nurse know and the nurse must call the pharmacy and get medication delivered that day. If mediation is unavailable, you must get medication out of the E-Kit and call the pharmacy to let them know you need the medication and notify them that you pulled the medication from the E-kit. Do not chart that the medication is unavailable. You must contact the physician and request a hold on the medication and request a medication that can be comparable to medication unavailable until you receive the medication ordered. You must document what you did, checked E-kit, called physician, etc. Triplicate requests are to be given to the DON on Monday and Wednesday every week to ensure we always have medications on hand when needed . Record review on a coaching form all nurses received from the facility documented the following: 1. If receiving a medication, medication must be signed into PCC and medication slip in binder in medication room. 2. If medication no on hand, nurse must check E-kit first, if not in E-kit, call pharmacy to get medication stated out. 675851 Page 3 of 4 675851 01/25/2024 Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

F 0760 3. Level of Harm - Minimal harm or potential for actual harm Call doctor to get different medication of same equivalency or placed on hold. 4. Residents Affected - Some Do not chart Medication on Order or Medication not available 5. Document what you did. 6. If triplicate needed, fill one out, fax and give completed documents to the DON on Mondays and Wednesdays of every week. Record review of the Off Cycle QA Meeting Document, dated 1/3/24, documented the following: On 1/3/24, QAAC Administrator and DON were informed that a medication was missed. A system failure was identified by Administrator and DON that resulted in an immediate need of review of this system. Areas of concern that were identified are listed below for review: Medication Administration/Missing Medications for Nursing. Administrator and DON/ADON initiated an action plan of compliance for medications not available. Coaching with all nurses who charted medication not available, in-service with nursing staff on medication administration/missing medications, medication audit to be performed daily to follow-up on medications that are held, put on as not available or on order. Nursing documentation will not state medication not available. Once Compliance is established, Administrator, DON, ADON or designee will monitor documentation, to ensure continuous compliance is met. If either party determines that the system is not in compliance at any time during monitoring, the system will be discussed with QAAC for an immediate change process. 675851 Page 4 of 4