Health inspection·November 20, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide pharmaceutical services, including the accurate administering of drugs for 1 of 5 Residents (Resident #1) reviewed for pharmacy services. 1) The facility failed to ensure Licensed Vocational Nurse (LVN) A did not administer PRN Ativan (Anti-Anxiety/Sedative medication), after it was ordered to be discontinued. The facility failed to remove anti-anxiety (Ativan) medication from the medication cart after it was ordered to be discontinued by the physician for Resident #1 The noncompliance was identified as past noncompliance. The noncompliance began [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. These failures could place residents who received medications at risk of receiving unnecessary doses of medication, experiencing undesirable side effects as well as potentially causing a physical or psychological decline in health. Findings include: Review of Resident #1's face sheet, care plan, MDS and Physician's orders revealed resident is a 75 -year-old female who was admitted on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease, Sjogren syndrome, Essential (Primary) Hypertension, and has a BIMS score of 11. Record review of Resident #1's orders showed an active order of for Tramadol HCl Oral Tablet 100 MG, give every six hours as needed for pain. Record review of Resident #1's orders showed a discontinued order for Lorazepam (Ativan) oral tablet 1 Mg, give every four hours as needed for anxiety and restlessness for 14 days discontinued on [DATE]. Record review of Resident #1's medication narcotic sheet dated [DATE]: 06:27 AM showed Ativan 2mg by mouth (PO) was administered versus the ordered Tramadol 100mg PO given by LVN A. Record review of nursing notes for Resident #1 revealed on [DATE]: 5:16 PM - Resident was transferred to a hospital on [DATE] 5:25 PM. Note states hospitalization was related to resident covid Page 1 of 3 675982 675982 11/20/2023 Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901

F 0755 positive at this time. Level of Harm - Minimal harm or potential for actual harm Record review of nursing notes for Resident #1 revealed on [DATE]: 2348 - Resident returned to the facility. Attempted to contact LVN A [DATE] at 2:00 PM. Unable to contact at this time. Residents Affected - Some In an interview on [DATE] at 10:31 am with Resident #1 she stated she is treated very well at this facility and has greatly enjoyed her stay. Resident #1 is observed to be ambulating in the room with oxygen on 4 Liters Per Minute (LPM). Resident #1 states she has been at the facility since about February and has no complaints. Resident states the staff at the facility are taking good care of her. Resident was unaware of receiving Ativan. In an interview on [DATE] at 1:45 PM with the DON, the DON states the medication error was discovered by the day shift nurse when the nurse was checking the narcotic drawer and noticed Resident #1's Ativan narcotic sheet had an entry for [DATE] at 6:27 AM. The nurse informed the DON of the medication error. In an interview on [DATE] at 10:20 AM with LVN C in regard to discontinued medications, she stated all narcotics that are to be destroyed have to be signed off by the DON. LVN C states the DON will perform a count of narcotics with her, sign the sheet, then take them to the locked area to be destroyed. In a phone interview on [DATE] at 8:31 AM with Resident #1's family member. Family member stated she was made aware of that Resident #1 was giving Ativan instead of Tramadol. In an interview with LVN B on [DATE] at 2:25 PM regarding discontinued medication process. She stated that all narcotics are handed over to the DON. For regular (non-controlled) medication that is discontinued, it is taken out of the cart, counted with a med aide, and put in a box in the medication room. Interview with CMA A on [DATE] at 2:30 PM regarding the discontinued medication process. She stated that all controlled drugs are given to the DON. CMA A stated that she will circle the amount remaining in the blister pack on the count sheet, sign, and date the count sheet once it is given to the DON. For regular medication that is discontinued, the drug name and count is placed on a Drug Destruction Log and the medication is locked and kept in the medication storage room. All the discontinued medications get placed in the DON's office and destroyed when the Pharmacist comes. Facility response because of medication error: 1. Inservice staff on the following: I. Medication administration [DATE] II. 675982 Page 2 of 3 675982 11/20/2023 Park Plaza Nursing and Rehabilitation Center 2210 Howard St San Angelo, TX 76901

F 0755 Controlled Drugs audit and accountability [DATE] Level of Harm - Minimal harm or potential for actual harm 2. Monthly Medication cart audits to check for expired and discontinued medication effective immediately. Residents Affected - Some 3. Pharmacy contract to assist with implementation and oversight of removing discontinued medication in medication cart at next visit. 4. Administrator will also conduct review of med cart as a fail-safe practice for facility. 5. Compliance Nurse will also take part in system develop to prevent recurrence. 675982 Page 3 of 3