Health inspection·November 20, 2023

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 interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of 6 (Resident #1) residents reviewed for medication administration. Residents Affected - Few -Resident #1 received Propranolol HCl oral tablet 20mg, over the course of 8 days, without an order. This failure could place residents who receive blood pressure medications at an increased risk for complications such as decreased blood pressure, decrease pulse, and an exacerbation of symptoms and disease process. Findings include: Record review of Resident #1's face sheet revealed an [AGE] year-old female re-admitted on [DATE] with diagnoses that included, but were not limited to, hypertensive urgency, essential hypertension, essential tremor, depression, anxiety disorder, muscle weakness and atrophy, not elsewhere classified, fibromyalgia, cognitive communication deficit, pain, unspecified fall, subsequent encounter, syncope and collapse, acute kidney failure. Record review of Resident #1's current MDS completed on 11/17/2023 revealed, in part, that her speech was clear, she was understood and understood others. She had a BIMS score of 15 out of 15, which indicated her cognition was intact. She was independent with partial/moderate assistance with some of her activities of daily living. She was occasionally incontinent of bladder and always continent of bowl. Record review of Resident #1's care plan, dated 11/08/2023, revealed, in part: Focus [Resident #1] has hypertension, date initiated 11/16/2023. Intervention .Evaluate blood pressure, date initiated 11/16/2023. Record review of Resident #1's admission orders, dated 11/03/2023, revealed, in part, that Resident #1 started Propranolol 20mg tablets, with a start date of 09/26/2023. Resident #1 stated that she was placed on the Propranolol for essential tremor, Resident #1 did not like how the medication made Page 1 of 2 675904 675904 11/20/2023 Windflower Health Center 5500 SW 9th Ave Amarillo, TX 79106

F 0760 her feel and she stopped taking the medication and had not been taking medication any longer. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's discharge orders from the hospital, dated 11/08/2023, revealed, in part, that Resident #1 would stop taking Propranolol 20mg tablet. Residents Affected - Few Record review of Resident #1's physicians orders, dated 11/16/2023, revealed, in part, May continue all medications and treatments as ordered from .hospital. Propranolol was not listed on the orders. Record review of Resident #1's MAR/TARs, dated 11/08/2023, revealed, in part, Propranolol was administered at 20:00pm with a blood pressure reading of 122/60 and a pulse of 74. The medication was given twice a day by mouth on 11/09/2023, 11/10/2023, 11/11/2023, 11/12/2023, 11/13/2023, 11/14/2023, and at 08:00am on 11/15/2023. Record review of Resident #1's progress note, 11/15/2023 at 10:30am, note placed in system by the MDS Nurse, reflected, admission care plan meeting held. [Family member] present in room. During review of medications a discrepancy was noted from what she (Resident #1) is currently receiving and what the dc orders from [hospital] were. [Family member] voiced concerns over this issue. I (MDS Nurse) walked back down with her to the patients room. I (MDS Nurse) told her I (MDS Nurse) would wait for the FNP to come out of another patients and address concerns and would follow back up with her. I (MDS Nurse) spoke with FNP about the medication discrepancy. She (FNP) had (LVN A) come over and they went through orders and corrections were going to be made. I (MDS Nurse) went and spoke with the [family member] and patient and let them know that it was being corrected. She [family member] at this time advised me that MD had wanted a BMP and renal function test done. FNP gave order for said labs and it was given to LVN A. I (MDS Nurse) followed up with the DON to make her aware of concerns. Resident was discharged home on [DATE] at 13:49pm. During an interview on 11/20/2023 at 4:26pm MDS Nurse stated that the floor nurse is responsible for transcribing orders received from outside sources. Whether it be a phone order from physician or incoming orders from a transferring facility. During an interview on 11/20/2023 at 4:32 RN C stated that the floor nurse is responsible for transcribing new orders for residents. During an interview on 11/20/2023 at 4:59 PM with RN B regarding Resident #1's Propranolol medication. RN B stated that the floor nurse received documents almost a week before the resident was admitted to the facility. Orders were placed into the system and when the new orders came with the resident on date of admission, they were never updated. Record review of facility provided policy titled, Medication Administration last review date 12/01/2021, reflected: .A medication profile, completed for each client at the time of medical admission, will be updated as indicated and reviewed at least every 60 days. The profile will include the name of the drug, date ordered, dose, route, frequency, duration of therapy if appropriate, action or effect, side effects and contraindications. This profile will include over-the-counter drugs and nutritional supplements. The profile may also serve as a tool for the purpose of client/caregiver education. 675904 Page 2 of 2