Health inspection·October 12, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 of 6 residents (Residents #8 and 13) reviewed for gastrostomy tube management, in that: 1. Staff N failed to check the placement of Resident #8's gastrostomy tube prior to administering feeding. 2. Staff E failed to check the placement of Resident #13's gastrostomy tube prior to medication administration. These failures could place residents with gastrostomy tubes at risk of aspiration, medical complications, and a decline in health due to inappropriate gastrostomy tube care and management. The findings included: 1. Record review of Resident #8's face sheet dated 10/12/23 revealed he was admitted on [DATE] with diagnoses that included cerebral infarction (an area of the brain that dies due to lack of blood flow), gastrostomy (artificial external opening into the stomach for nutritional support), dysphagia (difficulty swallowing). Under the section titled Special Needs NPO and G-tube were listed. Record review of Resident #8 Physician Orders List revealed an order dated 8/3/23 revealed an order for NPO with intermittent, small sips of water. An order dated 9/15/23 for JEVITY 1.5 CAL: 1 can per gastrostomy tube 8A,12P,4P daily, an order dated 8/3/23 that read: Check gastric residual volume prior to feeding, and an order dated 8/31/23 for Ritalin 5 Mg tablet: give 1 tablet by mouth at 3pm daily. Record review of Resident #8's Care Plan dated 8/3/23 revealed a Care Plan Description that read: Requires Feeding Tube for nutrition d/t CVA Jevity 1.5, and interventions that read: Check placement of tube before meds and feedings and Check for residual before initiating feeding. During an observation of medication administration on 10/6/23 at 3:02 pm, Staff N administered medications and a bolus feeding via G-tube to Resident #8. Staff N did not verify G-tube placement by Page 1 of 4 675890 675890 10/12/2023 The Heights at Medical Center 3935 Medical Dr San Antonio, TX 78229

F 0693 auscultation or aspiration prior to administering medications to the resident. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/12/23 at 5:24 pm with Staff N, she said she checked for G-tube placement once a week by checking residuals. Staff N said the facility policy was to check for placement using residuals and she had received a copy of the policy. She added the expectation was that G-tube placement be checked once a week. Staff N said that she checked the resident's orders prior to providing any feeding/medications. She added she reviewed care plans once a week and the expectation was, they were to be reviewed daily. Staff N said she did not check for placement of Resident #8's G-tube because she forgot. She said she had reviewed Resident #8's care plan the previous day (10/11/23) but was not aware that Resident #8 had an order that said the placement of the G-tube and residuals should be checked. Staff N said she had three residents with G-tubes and must have missed it. Staff N said it was important to check for G-tube placement and residuals because this was an aspiration risk, and she would not want fluid going into the resident's lungs. Residents Affected - Few 2. Record review of Resident #13's face sheet dated 10/12/23 revealed she was admitted on [DATE] with diagnoses that included hyperkalemia (elevated potassium levels), atherosclerotic heart disease (disease of the heart major blood vessels), muscle wasting, dementia, and gastrostomy (artificial external opening into the stomach for nutritional support). Under the section titled Special Needs G-tube was listed. Record review of Resident #13 Physician Orders List revealed an order dated 7/14/23 for Enteral-Residual check before H2O, medications, and formula. Record review of Resident #13's Care Plan dated 7/13/23 revealed an intervention that read: Check placement of tube before meds and feedings. During an observation of medication administration on 10/11/23 at 7:39 am, Staff E administered medications via G-tube to Resident #13. Staff E did not verify G-tube placement by auscultation or aspiration prior to administering medications to the resident. During an interview on 10/11/23 at 10:54 am with Staff E, she said Resident #13 did have an order to have G-tube placement checked, she added she usually checked for placement at the beginning of the shift. Staff E confirmed she did not check residuals before administering medications because the night shift checked Resident #13's residuals. Staff E said she did not know what the expectation was regarding checking for placement prior to accessing a G-tube. During an interview on 10/11/23 at 12:28 pm, Staff M said regarding checking for G-tube placement, if the G-tube was noted not to be in the same position or if the tube seemed clogged the doctor was called for an order for a scan to check for placement and residuals were to be checked before every feeding and medication administration. During a joint interview on 10/12/23 at 5:58 pm , with Staff L, ADON and Staff M, DON, Staff L said placement of G-tubes and residuals should be checked every shift at a minimum or before medication/feeding administration, she added that this was the facility's policy. Staff M said that he could not recall if any residents had orders for G-tube placement to be checked but that it was addressed in the care plans. Staff M said that all nursing staff were expected to follow all facility policies/procedures without exceptions and that Staff L, the ADON and Staff M, the DON were responsible for ensuring policies/procedures were followed. Staff L said that it was important to check for G-tube placement to ensure that contents were going into the stomach. Staff M said that it was important to 675890 Page 2 of 4 675890 10/12/2023 The Heights at Medical Center 3935 Medical Dr San Antonio, TX 78229

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ensure proper placement of the G-tube to prevent adverse reactions like contents going to another place other that the stomach. Staff L said that she was not aware of nurses not checking for placement or residuals. She said that her expectation was that nurses check the orders every shift at the beginning of the shift at a minimum and throughout the shift. Staff M said orders should be checked right before performing any skill/procedure, before interacting with the resident to ensure the nursing staff are following the correct orders. Staff M said it was expected for nurses to check G-tube placement and added the facility used residuals to check for G-tube placement. Staff M said he was not aware of nurses not checking for residuals prior to feedings. Staff L said checking residuals was important to ensure the G-tube was in the right place and ensure the resident was digesting the contents of the stomach, Staff M said this was also done to verify patency of the tube. Review of the facility's undated policy, titled Administering Medications through an Enteral Tube, revealed under Preparation, 1. Verify that there is a physician's medication order for this procedure 2. Review the resident's care plan to assess for any special needs of the resident. Under Steps in the Procedure, 18. Confirm placement of feeding tube 19. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. 20. Check gastric residual volume (GRV) to assess for tolerance of enteral feeding 21. When correct tube placement and acceptable GRV have been verified, flush tubing with 15-30 mL warm sterile water (or prescribed amount). 675890 Page 3 of 4 675890 10/12/2023 The Heights at Medical Center 3935 Medical Dr San Antonio, TX 78229

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to provide separately locked compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 medication rooms, in that, Controlled medications in the narcotic waste box were accessible to any employees who had the code for the medication room. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: During an observation of the medication room on 10/12/23 at 2:52 pm with Staff L present revealed, the narcotic waste bin was attached to the Passport (Medication dispensing machine). It contained a slot on the top of the box for disposal of controlled medications. The box was full, and medications could be accessed without unlocking the box. Staff L was observed pulling medications out of the narcotic waste bin without unlocking the box. During an interview on 10/12/23 at 2:53 pm, Staff L verified that the bin was full and controlled medications were accessible. She stated that the pharmacist comes monthly and removed all wasted medications, including narcotics, from the facility for destruction. During an interview on 10/12/23 at 3:00 pm, Staff M, the DON, said that the pharmacist comes monthly to remove all wasted medications, including narcotics, from the facility. Staff M added that the pharmacist had not come in October yet. Staff M said that the pharmacist came as needed if called by Staff M, but he had not called the pharmacist. Staff M stated that he was not aware that the narcotic disposal box was full. Staff M said that only certified medication aides and nursing staff had access to the medication room. Staff M said that he was responsible for ensuring narcotic medications were not accessible. He added that he assessed the box monthly prior to the pharmacist's removal, this was the only time he assessed the narcotics waste bin. During an observation and interview on 10/12/23 at 3:10 pm with Staff M present, Staff M verified that the narcotics waste bin was full, and medications could be accessed without unlocking the box. During an interview on 10/12/23 at 5:58 pm Staff M said that he was responsible ensuring facility policies were followed by the nursing staff. Regarding the narcotic waste bin, Staff M, the DON, said that monitoring the proper disposal of narcotics was important to prevent drug diversion and medication errors. Record review of the facility's Controlled Medication Disposal undated policy, revealed, 1. The director of nursing and the consultant pharmacist are responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. 675890 Page 4 of 4