Health inspection·March 27, 2024

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 1 of 4 residents (Resident #1) reviewed for medication administration. Residents Affected - Few The facility failed to ensure MA B administered Lorazepam 1mg tablet orally (to treat anxiety) to Resident #1 on 03/25/2024 according to physician orders. This failure could place residents at risk of receiving incorrect amounts of medication prescribed by their physician. Findings include: Record review of Resident #1's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (memory loss), insomnia (difficulty sleeping), history of falls and anxiety disorder (feeling of fear or uneasiness). Record reviewed of Resident #1's admission MDS, dated [DATE], reflected in Section C, a BIMS score of 07 out of 15, which indicated her cognition was severely impaired. Record review of Resident #1's physician's orders, dated 03/19/2024, reflected LORazepam Oral Tablet 1MG (Lorazepam) Give 1 tablet by mouth at bedtime for Anxiety Disorder Unspecified. Record review of Resident #1's MAR for March 2024 reflected Lorazepam Oral tablet 1MG give 1 tablet at bedtime was administered on 03/25/2024 at 8:00 PM. The Lorazepam listed with a time of 2000 (8:00 PM) as the time to give the medication per physician's order. Record review of Resident #1's Individual Control Drug Record, for Lorazepam 1MG, reflected Directions: 1-tab po qhs. The medication was administered on 03/25/2024 at 1912 (7:12 PM) and administered on 03/26/2024 at 0800 (8:00 AM). The signature on the record for date 03/26/2024 0800 was staff MA B. Record review of a progress noted for Resident #1, dated 03/26/2024 reflected Family Member, brought to this nurse [LVN A] attention that pt [Resident #1] was groggy this morning. After investigation, noted that pt [Resident #1] accidentally received lorazepam 1MG this morning instead of tramadol by the CMA [MA B] that was giving meds. Notified Family Member whom is in the building of med error. Notified Hospice nurses whom is also in the building. Notified DON. Notified MD - no new orders, just monitor, notified Administrator, and pharmacy, Resident #1 resting soundly in bed. Page 1 of 3 676318 676318 03/27/2024 Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Change in Condition report for Resident #1, dated 03/26/2024, reflected vital signs at 10:32 AM, blood pressure reading 99/58, pulse 64 and respirations 16 breaths per minute. During an interview on 03/26/2024 at 4:35 PM, The DON stated she was informed of the medication error on the morning of 03/26/2024 by LVN A. The DON stated LVN A reported to her MA B, accidentally gave Resident #1 her night Lorazepam in the AM. MA B pulled the Lorazepam from the cart not the Tramadol. The DON stated the family asked LVN A about Resident #1 being drowsy that morning. The DON stated LVN A and MA B reviewed the count sheet and medication card for the Lorazepam for Resident #1 and MA B administered the Lorazepam and signed the medication out on 03/26/24 at 8:00 AM. The DON stated LVN A notified the physician and there were not any new orders only monitor Resident #1. During an interview on 03/27/2024 at 9:48 AM, MD stated the facility notified him of a medication error for Resident #1 the morning of 03/26/2024. The MD stated the medication (Lorazepam) that was given to Resident #1 was her prescription and was ordered 1 tablet at bedtime. The MD stated Resident #1 had a PRN order for liquid Lorazepam as well since Resident #1 was on Hospice services, and if she were to need the liquid in the event, she was no longer able to swallow. The MD stated Resident #1 receiving the Lorazepam 1mg tablet in the morning could cause her drowsiness. The MD stated his expectations for the staff at the facility would be to re-educate, monitor and double check medication before giving. During an interview on 03/27/2024 at 10:45 AM, the Family Member stated while visiting Resident #1 on 03/25/2024 early morning it was noticed Resident #1 did not want to wake up or eat breakfast. The Family Member stated the nurse was asked about the medications Resident #1 took that morning and when Resident #1 last received the Lorazepam. The Family Member stated the nurse checked the medication record for Resident #1 and informed them Resident #1 had accidently been given the nighttime Lorazepam that morning at 8:00AM. During an interview on 03/27/2024 at 11:45 AM, the ADON stated she was told about the medication error for Resident #1 on the morning of 03/26/24. She stated staff made the notifications and completed an assessment on Resident #1 and completed the incident report. She stated staff should follow the 6 rules for medication pass when administering medication. During an interview on 03/27/2024 at 1:52 PM, Resident #1 stated no concerns with the facility or staff, and her pain was addressed and treated when needed. During an interview on 03/27/2024 at 2:46 PM, LVN A stated on 03/26/2024 a family member for Resident #1 asked her why Resident #1 was so groggy. She stated she told the family member she was not sure because Resident #1 had already been up and Hospice was in and bathed her. LVN A stated the family member asked, when did Resident #1 have her Lorazepam last, and she explained she would go check the records and find out. She stated she reviewed the record and noticed a Lorazepam was signed out as given that morning. LVN A stated she spoke with MA B and asked, if she gave Resident #1 a Lorazepam that morning and MA B yes by mistake. LVN A stated she notified the DON, Physician, Hospice and the family member and completed an assessment on Resident #1. LVN A stated she completed the medication report and spoke with MA B and explained staff must check the medication, dose, resident everything three times before the medication was given. LVN A stated Resident #1 did not experience any negative outcome form receiving the Lorazepam in the morning, Resident #1 slept that morning and was back to her baseline by the lunch meal. During an interview on 03/27/2024 at 3:57 PM, MA B stated during the medication pass on the morning 676318 Page 2 of 3 676318 03/27/2024 Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of 03/26/2024 she thought she pulled the Tramadol for Resident #1, but pulled the Lorazepam instead, and she should have done her three checks. She stated she didn't know Resident #1 had Lorazepam in the medication cart, but she checked the resident's name and that it is confusing and hard to explain, but maybe she was going too fast and should have check everything. MA B stated she was trained before giving any medication to check the right name, the right resident, the right medication, the right time, and that she thought she had followed the way she had been trained. MA B stated she checked the medication and information for the Lorazepam before she signed it out on the morning of 03/26/2024, to make sure it was the Lorazepam and that she signed the correct sheet. MA B stated she didn't know where her mind was at. MA B stated potential negative outcomes for residents that received medications at times not ordered were death, harm, hospital anything bad. MA B stated the facility provided in-service and trained to her on medication pass. During an interview on 03/27/2024 at 4:11 PM, the Administrator stated the DON informed him of the medication error by MA B. He stated the facility completed an assessment on Resident #1 and notified the physician, hospice and family. He stated the facility completed medication report and re-education MA B. The Administrator stated the potential negative outcome for residents who received medication at a time other than the time it was ordered, was it made her drowsy. The Administrator stated he expected staff to follow the five rights, the right medication is given, the right resident at the right time. Record review of the facility's, undated, Certified Medication Aide Job Detail provided by the facility documented: Certified Medication Aide . 1. Verifies identity of resident receiving medication and records name of drug, dosage, and time of administration on specified forms or records. Record review of the facility policy Administering Medications, dated 2001 (Revised April 2019), documented the following: Policy Statement: Medications are administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation . 3. Medications are administered in accordance with prescriber orders, including any required time frame . 6. Medications are administered within one hour of their prescribed time, unless otherwise specified for example, before and after meal orders . 9. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 676318 Page 3 of 3