Health inspection·November 20, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview, and record review, the facility failed to provide provide routine and emergency drugs and biologicals to its residents, or obtain them for 1 of 1 residents (Resident #1) reviewed for medications as evidenced by: The facility failed to transcribe physician orders correctly when Resident #1 returned from the hospital with discharge orders. This failure could place residents at risk of not receiving care and treatment to address their medical condition. Findings included: Record review of Resident #1's face sheet indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: hypertension, syncope and collapse, metabolic encephalopathy ( problem in the brain caused by a chemical imbalance in the blood), unspecified atrial fibrillation (irregular heart rate that causes poor blood flow), diabetes, dementia, depressive disorder, pseudobulbar effect( inapprpriate laughing or crying), hypo-osmality ( levels of electrolytes, proteins, and nutrients in the blood are lower than normal)and hyponatremia (low blood sodium), muscle wasting and hypothyroidism ( thyroid gland does not produce enough thyroid hormone). Record review of Resident #1's Quarterly MDS dated [DATE] indicated Resident #1 had a BIMS of 11 out of 15 which indicated cognition was moderately impaired. Record review of Resident #1's revised care plan dated 11/8/23 documented Resident #1 was on an anticoagulant which started 11/8/23 and documented the resident was at risk for bleeding. Review of hospital records revealed Resident #1 was admitted to the hospital for weakness on 10/22/23 and discharged on 10/27/23. Record review of Resident #1's facility physician's summary orders dated 10/1/23 thru 10/31/23 revealed, Apixaban (Eliquis) was not listed on the facility physician orders or the facility medication administration review. Record review of Resident #1's hospital discharge orders dated 10/27/2023 revealed an order for Apixaban 5 mg tablet- Take 2 tablets (10 mg total) by mouth 2 x's per day for 7 days, then 1 tablet (5mg) BID. Last time given was 10 mg on 10/27/23 at 8:47 am at the hospital. Commonly known as Eliquis. Page 1 of 2 676157 676157 11/20/2023 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's facility physician's summary orders dated 11/1/23 thru 11/30/23 revealed, Apixaban (Eliquis) was listed on the facility physician orders and was given beginning 11/8/23 on the facility medication administration review. In an interview on 11/13/22 at 8:20 am, the ADM stated Resident #1 went to the hospital and the hospital put resident on a blood thinner Apixaban. When Resident #1 was readmitted to the facility, RN A and LVN B, who were working on his re- admission on [DATE], missed the order for Apixaban. The ADM stated RN A and LVN B were terminated. She stated RN A and LVN B did not follow the procedure for readmission and should have caught the order. The ADM stated it was the expectation of the facility that all orders are followed completely. The ADM stated the consequences for not documenting all orders were residents will not get the correct medications or care. In an interview on 11/13/23 at 1:00 pm, the faciliy medical director stated he had taken Resident #1 off blood thinners in the past because it caused too much clotting. He stated Resident #1 had no medical issues because of the medication not being given from 10/27/23 to 11/8/23 and did not feel he had suffered any ill effects from not recieving the blood thinner. Record Review on 11/20/23 of the undated RN Supervisor Worksheet Checklist documented to: visually check on the new admits: all meds in house and available; all orders verified with the MD have been entered; admission readmission assessment has been started. Record Review on 11/20/23 of RN A's employee record revealed she was terminated on 11/10/23. Description of the incident on the Corrective Action Form documented: Employee falsified documentation. Veteran readmitted on [DATE] signed off on her supervisor report under admission that all medications were in house and available. All orders were verified with the MD and had been entered. admission Re admission assessment had been started. None of the above was completed or documented. Specific offense was documented as Willful falsification of information given to a supervisor. Falsifying or misrepresenting official company records. Negligence in the performance of assigned duties affecting health, safety and wellbeing of others. Record Review on 11/20/23 of LVN B's employee record revealed she was terminated on 11/10/23. Description of the incident on the Corrective Action Form documented: Employee failed to verify orders, enter orders, confirm orders with the NP/MD. Therefore, Veteran did not receive one medication that had been sent to initiate on the hospital discharge orders. Assumed the RN Supervisor on duty was completing. Specific offense was documented as neglect of duties/failure to perform duties specifically assigned by a supervisor. Negligence in the performance of assigned duties affecting health, safety and wellbeing of others. A policy on medication orders was requested on 11/20/23 at 3:00 pm but not provided. 676157 Page 2 of 2