Health inspection·August 25, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for accuracy of medical records in that: LVN A and LVN B did not document the administration of Invega Sustenna to Resident #1 for April, May, and June 2023. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: Record review of Resident #1's face sheet, dated 12/15/17, revealed Resident #1 was admitted to the facility on [DATE] with the following diagnoses: Unspecified dementia [loss of cognitive functioning], other schizophrenia [disorder affecting the ability to think, feel and behave clearly], major depressive disorder (severe, with psychotic symptoms) [disorder that causes persistent depressed mood], anxiety disorder [disorder that causes feelings of worry or fear]. Record review of Resident #1's admission MDS, dated [DATE], revealed Resident #1 had a BIMS score of 8, suggesting moderate cognitive impairment. Record review of Resident #1's MARs revealed that Invega Sustenna 117 MG/0.75ML was not administered on 4/13/23, 5/13/23 or 6/13/23. Record review of Resident #1's Physician Orders revealed an order for Invega Sustenna Suspension Prefilled Syringe 117 MG/0.75ML (Paliperidone Palmitate ER) Inject 117 mg intramuscularly one time a day starting on the 13th and ending on the 13th every month related to OTHER SCHIZOPHRENIA. Record review of Resident #1's progress notes indicated the following: - 4/13/23 by LVN C, reflected pending pharmacy, - 5/13/23 by LVN C, reflected medication not available pending pharmacy delivery due to weather conditions delivery delayed, and - 6/13/23 by LVN D, Pending arrival from pharmacy. Page 1 of 3 675883 675883 08/25/2023 Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/23/23 at 2:10 pm the IDON said that the Pharmacy A representative told her that Resident #1's Invega injection was requested by the facility on 4/13/23 and delivered on 4/14/23, on 5/13/23 and delivered 5/14/23, and on 6/13/23 and delivered 6/15/23. Record review of Pharmacy A's Packing Slips verified Invega Sustenna 117MG/0.75ML for Resident #1 was delivered to the facility on: 4/14/23 at 4:00 am and was signed for by RN C, 5/14/23 (no time specified) and was signed for by LVN B, and 6/15/23 at 3:47 am and was signed for by LVN B. During an interview on 8/23/23 at 11:29 am LVN A said the number 9 on the MAR meant the medication was not given for some reason and that the reasons were documented in the progress notes. She verified that her initials were [LVN A's initials] and that she documented on Resident #1's MAR a 9 on 4/13/23 and 5/13/23. LVN A said that Resident #1 did not receive the Invega injection on 4/13/23 and 5/13/23 because it was not available, she added that she had ordered it from the pharmacy, but it did not arrive on the day the medication was due to be administered. LVN A stated the facility's nurses were responsible for ordering medications when they were out. LVN A stated she documented in the progress notes that the medication was pending from the pharmacy. LVN A said she did not administer the medication because she was not at the facility when it was delivered. She added that she did not remember but said she was sure she did not work on 4/13/23. She said she was sure the injection was administered because Resident #1 had not had any changes in mood or behavior but could not remember administering the injection. LVN A said the Invega injection's administration should have been documented in the progress notes by the nurse administering it. She added that the nurse that was on shift when the medication was delivered should have administered and documented it. LVN A said she did document that it was not available and notified the NP that the medication was not available. During an interview on 8/23/23 at 1:16 pm the ADON said that he had started working at the facility less than 90 days ago and was not aware that Resident #1 had not received the Invega injection on 4/13/23, 5/13/23 and 6/13/23. The ADON stated there had not been reports from the staff or the NP, who visits the facility every day, regarding changes in Resident #1's mood or behavior. The ADON said it was important that Resident #1 received the Invega injection every month because it affects her mood and behaviors and a lapse in the administration of the medication was not good because it needed to reach a therapeutic level. The ADON said the Invega could not be ordered before the 13th of the month because the insurance did not allow it and only covered the medication when ordered every 30 days. During a telephone interview on 8/23/23 at 3:53 pm the Pharmacist from Pharmacy A said she was not able to find evidence that the insurance rejected payment for the refill of Invega, she added that Resident #1's insurance plan did allow the medication to be filled a few days before it was due to be administered. During an interview on 8/23/23 at 4:25 pm the DON said the software used by the facility did not allow the facility to order the Invega injection until the 13th of every month, which is when Resident #1's Invega injection was due. During an interview on 8/23/23 at 3:25 pm the NP said that he was notified that the medication Invega was not administered to Resident #1 due to it not being available on 4/13/23, 5/13/23, and 6/13/23. He added that the nurses were told to administer the medication as soon as it arrived at the facility. The NP said he saw the resident monthly, and she had been stable, there had not been any changes in mood or behaviors, she had been doing well and had been very pleasant. 675883 Page 2 of 3 675883 08/25/2023 Southeast Nursing & Rehabilitation Center 4302 E Southcross Blvd San Antonio, TX 78222

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 8/23/23 at 5:00 pm LVN A said she has been under a lot of pressure and did not remember if she administered the Invega to Resident #1 in April. During a telephone interview on 8/23/23 at 6:36 pm LVN B stated she received Resident #1's Invega injection on 5/14/23 and 6/15/23. She said that she administered the injection after they arrived. LVN B said that she did not document the administration on the MAR because the slots were filled, and she was not able to check the boxes on the MAR on the day it was administered. She added that she notified the following shift verbally that she had administered the injection but did not document this in the progress notes. LVN B said she was required to document the injection's administration in the progress notes. She added that she had received training regarding medication administration, documentation, communication, and MD notification. LVN B said she received this training upon hire and on 8/23/23. During a telephone interview on 8/25/23 at 8:57 am RN C stated she received Resident #1's Invega injection on 4/13/23 but did not administer it. During a telephone interview on 8/25/23 at 11:00 am LVN D said the number 9 on the MAR meant other. LVN D stated her initials were [LVN D's initials], that she documented on Resident #1's MAR a 9 on 6/13/23 and documented in the progress notes that the medication was pending from pharmacy. LVN D said she was sure that LVN A administered the injection but did not know if LVN A documented the administration. LVN D said that she was sure that LVN A administered it because she took the injection out of LVN D's medication cart and told LVN D that she had forgotten to administer it and was going to administer it. LVN D said she did speak with the NP to get an order for late administration of the Invega injection. LVN D said that there had been no changes in Resident #1's mood or behavior noted or reported. During a telephone interview on 8/25/23 at 11:44 am the Administrator said that LVN A was under a lot of pressure and stress due to all the responsibilities she has been given at the facility. Record review of a facility policy titled, Medication - Treatment Administration and Documentation Guidelines, dated 2/10/2020, revealed the following, document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. 675883 Page 3 of 3