Health inspection·April 18, 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 pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to administer Resident #1's hydrocodone-acetaminophen tablet on 04/17/23 at 12:00 AM, 04/17/23 at 12:00 PM, and 04/18/23 at 12:00 AM. This deficient practice could place residents at risk of not receiving the therapeutic effect of medications and a drug diversion. The findings included: Resident #1 A record review of Resident #1's electronic Facesheet, dated 04/18/23, revealed he admitted to the facility on [DATE] with diagnoses which included: muscle wasting generalized, cervical disc disorder at c6-c7 level with radiculopathy (nerve root is irritated, the symptoms usually include neck pain and pain in the arms, weakness in the hands and weakness in the arms, shoulder pain, chest pains, uncontrollable sweating, headaches, and possibly more), cerebral infarction (stroke), and pain in joints right and left hand. A record review of Resident #1's quarterly MDS, dated [DATE] revealed a BIMs score of 10, which indicated the resident's cognition was moderately impaired. Further review of the MDS revealed Resident #1 was to receive scheduled pain medication regimen. A record review of Resident #1's comprehensive care plan dated 01/04/22 revealed a focus that Resident #1 required pain management due to chronic pain related to diabetic neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) and fracture. An intervention included Administer analgesia (specify medication) as per orders. A record review of Resident #1's Order Summary for April 2023 revealed a physician order for Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet by mouth every 6 hours for pain management. Start date 12/13/22. A record review of Resident #1's MAR, dated April 2023, revealed the following: Page 1 of 3 676270 676270 04/18/2023 Brentwood Place Four 3505 S Buckner Blvd Bldg 5 Dallas, TX 75227

F 0755 Level of Harm - Minimal harm or potential for actual harm - Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet by mouth every 6 hours for pain management. Start date 12/13/22 0000 (12:00 AM), 0600 (6:00 AM), 1200 (12:00 PM), and 1800 (6:00 PM). There were initials but there were no check marks and number 9 were listed for the following times: 04/17/23 at 12:00 AM, 04/17/23 at 12:00 PM, and 04/18/23 at 12:00 AM. The chart codes listed 9=Other/See Nurse Notes. Residents Affected - Few A record review of Resident #1's Progress Notes in his medical record revealed on 04/17/23 at 01:37 LVN A documented Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for pain. On 04/17/23 at 06:50 LVN A documented Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for pain. On 04/18/23 at 05:41 LVN A documented Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for pain. In an interview on 04/18/23 at 11:06 AM Resident #1 stated he did not receive his hydrocodone pain medication yesterday (04/17/23). He stated the facility did not have his night dose of medication two nights in a row and they did not have afternoon dose yesterday (04/17/23). He stated the nurses told him they had ran out of his medication. Resident #1 stated he was not too worried about afternoon does, but it was the night dose that really made him feel pain. He stated he was going from 12:00 AM to 6:00 AM without pain medication and he could not sleep. Resident #1 stated he was up all night tossing and turning from being in pain. In a phone interview on 04/18/23 at 04:11 PM LVN A stated he worked the overnight shift from 10:00 PM to 06:00 AM on 04/16/23 and 04/17/23. LVN A confirmed how his initials would display on Resident #1's MAR. He stated when you were unable to administer the medication there would not be a check mark on the MAR and instead would be your initials and then you would have to code a reason it was not administered. LVN A stated when the medicine was not available you were supposed to document a number 9. He stated he was unable to give Resident #1 his medication overnight because it had run out. LVN A stated he contacted the pharmacy on 04/17/23 between 11:30 PM to12:00 AM in attempt to retrieve Resident #1's medication from the facility's emergency kit, but the pharmacy told him the medication was on the way to the facility. LVN A stated the medication arrived about 3 to 4 AM. He stated he did give Resident #1 his 6:00 AM dose at approximately 5:00 AM. LVN A stated when the resident's medications got down to like 8-10 pills the Med Aides were supposed to notify the nurse to request a refill. LVN A stated, apparently the Med Aides had not notified the nurses that the hydrocodone was low. LVN A stated this was a risk to the resident because he could be in pain, due to not having the medication. In an interview on 04/18/23 at 04:32 PM, RN B stated the Med Aide C told her Resident #1's hydrocodone medication was out. RN B stated she contacted the pharmacy in attempt to provide Resident #1 his medication from the emergency kit, but the pharmacy would not authorize it because the medication required a triplicate and the pharmacy had not received it from the physician. RN B stated she contacted the physician via text message on 04/17/23 at 1:32 PM to have the triplicate signed and sent to the pharmacy. In an interview on 04/18/23 at 4:48, Med Aide C stated she was unable to administer Resident #1's hydrocodone on 04/17/23 because it had not been refilled. She stated she did notify RN B. Med Aide C stated when medication was down to about 10 pills, they were supposed to notify the nurse the medication needed to be refilled. She stated she noticed the pills were low on Saturday 04/15/23 and she notified the charge nurse the medication needed to be refilled. Med Aide C stated she could not recall who the nurse was, but she did notify them the medication was low. 676270 Page 2 of 3 676270 04/18/2023 Brentwood Place Four 3505 S Buckner Blvd Bldg 5 Dallas, TX 75227

F 0755 Level of Harm - Minimal harm or potential for actual harm In an interview on 04/18/23 at 3:29 PM, the DON stated she was unaware that Resident #1 was not getting his hydrocodone medication. She stated the expectation was for Med Aides to notify the nurses when medications were down to a 7-day supply, so that the nurses could request them be refilled. She stated Resident #1 not having his medication could cause him to be in pain. The DON stated she would in-service the staff immediately about medication refills. Residents Affected - Few The record review of facility's policy, titled Medication-Administration, dated May 2017, revealed It is the policy of this home that medication will be administered and documented as ordered by the physician and in accordance with state regulations. 676270 Page 3 of 3