Health inspection·September 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 remained free of any significant medication errors for 1 of 6 residents reviewed for medication errors (Resident #1). Residents Affected - Few RN A incorrectly administered another resident's Metoprolol Tartrate Oral tablet 25mg to Resident #1. The significant medication error caused Resident #1 to have an altered blood pressure requiring transfer to the local hospital for further evaluation. The facility's failure could place residents at risk for adverse reactions, health complications and hospitalization and death. Findings include: Record Review of Resident #1's facility clinical record revealed: Resident #1 was a [AGE] year-old female with an admission date of 8/16/23. She was admitted to the facility for rehabilitation services after a diagnosis of pneumonia in the community. Resident #1 had diagnoses of pneumonia, unspecified protein calorie malnutrition, chronic pain, unsteadiness on feet, muscle wasting, major depression, single episode. Resident #1 was discharged home on 9/15/23 after the emergency room visit. Record Review of Resident #1's MDS, dated [DATE], indicated the following: Resident #1 had adequate vision and hearing; BIMS-14, was independent in bed mobility, transfers, dressing, and toileting, independent in mobility; had no upper or lower extremity impairment; was occasionally incontinent of bowel and bladder; had some complaints of pain requiring medication; and was at risk for falls. Record Review of the care plan for Resident #1, dated 8/16/23, indicated: Resident #1 was independent in activities of daily living, had pain, and was at risk for falls. Record Review of the Physician's Orders for Resident #1 dated 8/16/23 to 8/31/23 and 9/1/23- 9/30/23, revealed no orders for Metoprolol. Record Review of Resident #1's facility progress notes dated 9/15/23 at 12:03 pm stated: Blood pressure medication Metoprolol administered in error by RN A. Immediate assessment completed. Page 1 of 3 675973 675973 09/20/2023 McLean Care Center 605 W Seventh St McLean, TX 79057

F 0760 Level of Harm - Minimal harm or potential for actual harm Resident was alert, oriented and has no signs of lethargy or distress. Manual blood pressurewas 82/58. NP notified, and orders received to send resident to the emergency room for closer evaluation. Record Review of the facility, Medication Error Forms, for Resident #1's medication error dated 9/15/23 at 12:04 pm stated: Residents Affected - Few Blood pressure medication Metoprolol administered in error by nurse. Immediate assessment completed. No signs of lethargy or distress. Manual blood pressure 82/58. NP notified and orders received to transfer resident to emergency room. Record Review of the facility incident report for Resident #1's medication error dated 9/15/23 at 12:05 pm indicated: Blood pressure medication Metoprolol administered in error by nurse. Immediate assessment completed and resident showed no signs or symptoms of distress or lethargy. Resident had a history of hypotension. Manual blood pressure 82/58. NP notified and orders received to transfer resident to hospital. Resident #1 was alert and oriented. Resident #1 stated she did not feel any different than normal. Resident was oriented to time place and person. Predisposing physiological factors- hypotensive. During an interview on 9/20/23 at 10:00 a.m., RN A stated she was the nurse that committed the medication error while caring for Resident #1. RN A stated she was completing med pass when she was distracted and overwhelmed with other residents asking for her attention and a resident wandering into the covid rooms. She stated was redirecting the wandering resident and trying to assist the other residents with their requests and was not thinking when she gave the Metoprolol to Resident #1 instead of the correct resident. She stated shortly after giving the medication to Resident #1 she realized she had given the medication to the wrong resident. During an interview on 9/20/23 at 1:00 pm, Resident #1's family member (Family Member #2) stated there was no significant problem to Resident #1 after the wrong medication was given. She stated the hospital told her Resident #1 's vital signs were normal, and she did not have any aftereffects of being given the medication. Family Member #2 stated RN A was a good nurse, and she did not give Resident #1 the medication on purpose. During an interview on 9/20/23 at 2:00 pm, the MD stated he was aware of the wrong medication being administered to Resident #1. He stated her blood pressure did go down to the 80's and she was sent to the hospital emergency room. MD stated she did not require any treatment at the emergency room because of this. The MD stated the metoprolol has a 12-hour half-life and within 6 hours we would not expect her to have any ill effects. During an interview on 9/20/23 at 2:45 pm, the DON stated she was notified immediately after the medication error and an assessment was started. The DON stated Resident #1's blood pressure was 82/58. The NP was contacted, and the resident was sent to the emergency room. The DON stated she believed this happened because the nurse was on the way to give the medication and was interrupted with a situation involving another resident needing immediate attention. The DON stated she was responsible for the actions of the nurses and has in-service and trained all the nurses in medication administration. The DON stated the consequences of this incident could be death, confusion, or an allergic reaction of a resident to the wrong medication. During an interview on 9/20/23 at 2:55 pm, the ADM stated she was notified immediately after the 675973 Page 2 of 3 675973 09/20/2023 McLean Care Center 605 W Seventh St McLean, TX 79057

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication error and an assessment was started on Resident #1. The ADM stated she thought RN#1 was overwhelmed accidentally gave the medication to the wrong resident. The ADM stated to ensure this does not happen again, all nurses were in-serviced on medication administration and felling overwhelmed. The ADM stated the DON was also doing med pass monitoring for the next month. The ADM stated the consequences of a resident getting the wrong medication was death, or an allergic reaction to the wrong medication. Record Review of the facility policy titled, Medication Administration Procedures, dated 2003, stated: Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered. Medications prescribed for one resident are not to be administered to any other resident. Medication errors are immediately reported to the resident's physician. In addition, the DON should be notified of any medication errors. 675973 Page 3 of 3