Health inspection·March 4, 2025

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 five (Resident #1) residents reviewed for medication administration. Residents Affected - Few -Resident #1 received a dose of 100units of insulin glargine instead of the prescribed 11units on the evening of 02/16/2025 in error. This failure could place residents who receive insulin medications at an increased risk for complications such as decreased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 02/16/2025 and ended on 02/17/2025. The facility corrected the noncompliance before the investigation began. Findings include: Record review of Resident #1's most recent face sheet revealed a [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses that included, but not limited to, congestive heart failure, hypothyroidism, type 2 diabetes mellitus without complications, hypertensions (high blood pressure). Record review of Resident #1's current MDS, dated [DATE], revealed, in part, that Resident #1 had a BIMS score of 13 out of 15, which indicated her cognition was not impaired. She was dependent upon staff for putting on/taking off footwear, lower body dressing, and toileting hygiene, all other care areas Resident #1 needed setup or clean-up assistance or supervision or touching assistance. Section N-Medications revealed that Resident #1 was on insulin and had received it over the past 7 days. Record review of Resident #1's care plan, dated 01/09/2025, revealed, in part the following: Diabetes: [Resident #1] has Diabetes Mellitus Medication Insulin Lispro (SSI) nsulin Lispro . Page 1 of 7 676186 676186 03/04/2025 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0760 . Goal: The resident will have no Level of Harm - Minimal harm or potential for actual harm complications related to diabetes through the review date . Residents Affected - Few . Interventions/Tasks Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Date Initiated: 01/02/2025 o Educate resident/family/caregiver: Diabetes is a chronic disease and that compliance is essential to prevent complications of the disease, Review complications and prevention with the resident/family/caregiver, Elicit a verbal understanding from the resident/family/caregiver, That nails should always be cut straight across, never cut corners. File rough edges with emery board. Date Initiated: 01/02/2025 o Fasting Serum Blood Sugar as ordered by doctor. Date Initiated: 01/02/2025 o Monitor compliance with diet and document any problems. Date Initiated: 12/26/2024 o Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Date Initiated: 01/02/2025 o Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. 676186 Page 2 of 7 676186 03/04/2025 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0760 Date Initiated: 01/02/2025 . Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's physician's orders dated 03/04/2025 revealed in part, Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine), Inject 11 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9). Residents Affected - Few Record review of Resident #1's MAR/TAR dated 03/04/2025 revealed in part, on 02/16/2025 LVN A documented a blood sugar of 134 and checked that she gave Resident #1 her 11 units of Insulin Glargine. Record review of Resident #1's progress note dated 02/17/2025 at 02:41 revealed that res. Returned to facility via facility van [local hospital] called to pick up after valuation. Last glucose at the hospital was 134mg/dl. Resdenies any c/o pain or discomfort at this time. She is alert and oriented x3. V/S within normal baseline. Glucose checks noted q2hrs. on EMAR. Progress note dated 02/17/2025 at 03:09 revealed that glucose check was 129mg/dl. Res. Awake on her phone no complaints verbalized. Progress note dated 02/17/2025 at 04:16 revealed glucose at 98mg/dl-Snack given to resident. She is awake and alert eating pudding and crackers. This writer will cont. to monitor and document glucose checks as scheduled. Progress note dated 02/18/2025 at 04:15 revealed Res has completed hourly glucose checks. No episodes of hypoglycemia noted. Res. Has slept at short intervals throughout the night. Res is offered H2O and snacks when awake. Res. Denies any c/o pain or discomfort. She is alert and oriented x3. Resp areeven and non-labored V/s within baseline noted on EMAR. Record review of Resident #1's glucose log revealed the following: 02/16/2025 19:12 134 mg/dL 02/16/2025 21:21 134 mg/dL 02/17/2025 02:44 135 mg/dL 02/17/2025 04:15 98 mg/dL 02/17/2025 05:02 169 mg/dL 02/17/2025 05:22 149 mg/dL 02/17/2025 06:51 144 mg/dL 02/17/2025 08:03 156 mg/dL 02/17/2025 08:22 148 mg/dL 02/17/2025 10:06 165 mg/dL 02/17/202511:10 156 mg/dL 676186 Page 3 of 7 676186 03/04/2025 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0760 02/17/202511:51 182 mg/dL Level of Harm - Minimal harm or potential for actual harm 02/17/2025 13:08 165 mg/dL 02/17/2025 14:04 217 mg/dL Residents Affected - Few 02/17/2025 15:10 200 mg/dL 02/17/2025 16:07 217 mg/dl 02/17/2025 17:13 167 mg/dl 02/17/2025 17:35 170 mg/dl 02/17/2025 18:33 110 mg/dl 02/17/2025 20:00 113 mg/dl 02/17/2025 21:04 129 mg/dl 02/17/2025 22:26 122 mg/dl 02/18/2025 04:10 110 mg/dl Record review of facility investigation provided by ADM, untitled, undated revealed that LVN A self-reported that she administered 100units of Lantus insulin to Resident #1. Resident #1 was transported to ER via EMS for further evaluation. LVN A was relieved of duty and instructed to not administer any additional medications to residents and to wait for nursing relief to get to facility. Record review of in-service for medication administration, dated 02/17/2025, staff was educated on medication administration and the 6 Rights of medication administration. During an interview on 03/04/2025 at 10:46am Resident #1 stated that she remembers the incident with the insulin, and she stated, I am not sure why everyone was making such a big deal about it, I felt fine. I never felt bad. The nurse was checking in on me all the time, they put a trash can by the bed, like I was going to throw up or something. I did get a soda and I was kind of excited about it. But everyone was kind of freaking out and they called my brother, and he was really angry, not real sure why. I was told that I was given double the amount of medication that was supposed to be given. To be honest I wasn't really sure what was going on, until I was told about getting to much medicine. But I was fine, I didn't want to go to the ER, but the nurse let me know that I needed to be watched more closely than normal, so I went. During an interview on 03/04/2025 at 10:58am DON stated that the evening of the medication error took place she had received a phone call from LVN A stating that she had made a medication error. LVN A stated that she gave 100units of insulin the Resident #1 and asked the DON if she just want her to monitor her. DON stated to LVN A to hang up the phone and call 911. Resident #1 refused to go to the hospital with EMS. Resident #1 kept saying that she felt fine and was not exhibiting any symptoms of hypoglycemia. The CO-RN for the facility was able to talk Resident #1 into going to the hospital with EMS. DON stated that she called the facility back and told the other nurse that was working 676186 Page 4 of 7 676186 03/04/2025 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0760 Level of Harm - Minimal harm or potential for actual harm that night to go and get the LVN's keys and relieve her of her duties, until another nurse could get to the facility. LVN A was asked if she had given any other residents insulin that night and she had stated that she had not. DON stated that all other insulin dependent residents were observed just in case the LVN A was not telling the truth. DON stated that the CO-RN called the agency and put stipulations into place so that nurses with little to no experience were allowed to work in the facility. Residents Affected - Few During a phone interview on 03/04/2025 at 4:09pm with CO-RN stated that LVN A was no longer too able give any further medication to any other residents and had to wait outside the facility until her replacement got to the facility. The way LVN A spoke to CO-RN was that LVN A was just ok with what she did and there was no importance to what she did. CO-RN stated that she reported LVN A to the Texas BON and was unable to provide the referral # but will email the information to the investigator. CO-RN stated that she spoke with a physician, and it was stated to her that since the insulin was Lantus which is a long-acting insulin the monitoring of Resident #1 in the ER for only a few hours is standard protocol. If the insulin was a short acting insulin the situation would be very different. On 03/04/2025 at 4:21pm Investigator attempted to interview LVN A. Had to leave a voicemail with contact information for LVN A to call back. During a phone interview on 03/06/2025 with MD he was aware of the insulin error that took place at the facility. MD stated that Resident #1 did not have any harmful side effects from this error and was monitored very closely by the hospital and facility staff upon her return. Investigator did ask MD why the resident was only monitored for only a few hours in the hospital ER and if that was normal protocol. MD stated that the ER would monitor the resident and if she started to crash from the large amount of insulin they would give her Dextrose/10 infusion to help stabilize her blood glucose. However, Resident #1 never experienced any drop in her blood sugars. MD stated that a negative outcome would have been Resident #1 could have experienced hypoglycemic coma and would have had to be airlifted to a larger hospital for more intense interventions if it would have been a short-acting insulin. Record review of facility provided policy titled, Medication Administration, undated, revealed in part, the following: .10. Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation 11. Review MAR to identify medication to be administered. 676186 Page 5 of 7 676186 03/04/2025 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0760 Record review of facility provided policy titled, Medication Error undated, revealed in part the following: Level of Harm - Minimal harm or potential for actual harm It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Residents Affected - Few .Definitions: . . Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety. . Policy Explanation and Compliance Guidelines: 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders. b. Per manufacturer's specifications regarding the preparation, and administration of the drag or biological. c. In accordance with accepted standards and principles which apply to professionals providing services. Record review of facility provided policy titled, Timely Administration of Insulin, undated revealed in part the following: Policy: It is the policy of this facility to provide timely administration of insulin in order to meet the needs of each resident and lo prevent adverse effects on a resident's condition. . Policy Explanation and Compliance Guidelines: 1. All insulin will be administered in accordance with physician's orders. .5. Procedure: a. Review the insulin order: i. Resident name. 676186 Page 6 of 7 676186 03/04/2025 Castro County Nursing & Rehabilitation 1621 Butler Dimmitt, TX 79027

F 0760 ii. Medication name. Level of Harm - Minimal harm or potential for actual harm iii. Medication dosage. iv. Time to be administered. Residents Affected - Few v. Route of administration. . c. Prepare insulin dose. Before administering insulin, perform verification of correct resident, dose calculations, and correct route of administration. 676186 Page 7 of 7