Health inspection·September 14, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Residents Affected - Few Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (400 hall medication cart) reviewed for drug security. The 400 Hall nurse's medication cart was left unattended with a blister package of medication Tamulosin HCL for Resident #4 on top of the cart. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Record review of Resident #4's admission Record (face sheet), dated 9/14/24, revealed he was admitted to the facility on [DATE] with diagnoses which included Benign Prostatic Hypertrophy (an enlarged prostate) and history of lung cancer. Record review of Resident #4's Physician Order Summary, dated 09/14/2024, revealed an order for Tamulosin HCL capsule 0.4 mg give 1 capsule by mouth once a day for urine retention with a start date of 09/13/2024. Observation on 09/14/2024 at 5:21 a.m. of the 400 hall medication cart revealed that it was at the end of the hall. A blister package of Tamulosin HCL 0.4 mg (medication to treat Benign Prostatic Hypertrophy-enlarged prostate) with 14 tablets for Resident #4 was on top of the cart. Observation of the hallway at this time revealed there was no nurse in sight of the cart, there were no residents in the hallway, and anyone who walked by could have grabbed the medications. Observation and interview on 9/14/2024 at 5:23 a.m. revealed RN A came out of a nearby room. RN A, stated the cart with the medications on it was her medication cart, the medication on top of the cart were for Resident #4 that she was going to put back into the cart but didn't because it had been a crazy night. RN A said the medication should have been locked in the medication cart and should not have been left on top of the cart unattended. In an interview on 09/14/2024 at 2:16 p.m., the DON stated medications should be stored inside the Page 1 of 2 676158 676158 09/14/2024 Sonterra Health Center 18514 Sonterra Place San Antonio, TX 78258

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication cart and not on top of the cart because residents could take the medications and ingest the medication, or the medications could be diverted. The DON stated the nurse, or the medication aide were responsible for ensuring the medications were secured. The DON said the nursing staff were monitored by the nurse managers who did rounds on the halls. In an interview on 09/14/2024 at 2:33 p.m., the Administrator stated medications should be stored inside the medication cart or in the medication room and they should not be stored outside the cart or on top of the cart. The Administrator stated the harm that could happen with medications stored on top of a medication cart could result in drug interactions [if ingested]. The Administrator said the nurse who had the keys to the medication cart was responsible for ensuring medications were secured and the clinical leadership team was responsible for monitoring medication was stored securely. Record review of the facility's undated Medication Access and Storage Policy revealed It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 676158 Page 2 of 2