Health inspection·August 2, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 16 residents (Resident #30) reviewed for quality of care. Residents Affected - Few The facility failed to follow a physician order dated 07/11/23 to increase Resident #30's insulin from eight units to ten units. This failure could place residents at risk of uncontrolled blood sugar and kidney injury. Findings included: Review of the undated face sheet for Resident #30 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia, type II diabetes mellitus, and long term (current) use of insulin. Review of the annual MDS for Resident #30 dated 07/10/23 reflected a BIMS score of 11, indicating moderate cognitive impairment. It also reflected Resident #30 received insulin injections for seven of the seven days captured by the assessment. Review of the care plan for Resident #30 with a target date of 10/10/23 reflected the following: The resident has Diabetes Mellitus. The resident will be free from any s/sx of hyperglycemia through the review date. The resident will have no complications related to diabetes through the review date. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Fasting Serum Blood Sugar as ordered by doctor. Review of active physician orders for Resident #30 dated 06/16/23 reflected the following order: Levemir FlexTouch Solution Pen-injector 100 UNIT/ML (Insulin Detemir) Inject 8 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA Review of the July 2023 MAR for Resident #30 reflected her fasting blood sugars ranged from 147 to 353 with a reading of 214 prior to the administration of insulin on 07/31/23. It reflected she was administered eight units during the AM medication shift (precise times not available) from 07/11/23 to 07/31/23. Review of laboratory results of a blood specimen taken from Resident #30 on 07/05/23 reflected her A1C result (a test that measures the amount of hemoglobin {red blood cells} with attached glucose {sugar} and reflects a three-month average for blood sugar levels) was 8.9, which was marked high. The Page 1 of 3 676399 676399 08/02/2023 San Saba Nursing & Rehabilitation 2400 West Brown Street San Saba, TX 76877

F 0684 normal reference range was denoted as 4.0-5.6. Level of Harm - Minimal harm or potential for actual harm Review of nursing progress notes dated 7/11/2023 at 10:03 AM and documented by LVN A reflected the following: New order per (MD) to increase Levemir to 10 units QAM due to elevated A1C level. RP notified. Residents Affected - Few During an interview on 08/01/23 at 10:52 AM, the MD stated the order should have been entered when he made it, but he had no reason to think it had a profound effect on Resident #30 in the short term. He stated he had examined Resident #30 that morning, and she was fine. He stated the A1C was an average, and her blood sugars had been up and down. He stated the changes to insulin dosage were part of a long-term plan to treat her diabetes, not an urgent or emergent response. During an interview on 08/02/23 at 11:50 AM, LVN A stated she had no idea why the order for Resident #30's increase in insulin did not get entered. She stated she had a regular process she always used: she entered the order in the EMR first, called the resident's responsible party, wrote a nursing progress note, and then she put it in the 24-hour communication book. LVN A stated she could not tell why she failed to get the order into the EMR but took all the other steps, because it was a few weeks back. LVN A stated her process was her own and not specifically how any of her nurse managers instructed her to proceed. LVN A stated a potential negative impact on the resident was her sugars could have stayed too high and caused kidney problems. During an interview on 08/02/23 at 12:01 PM, the DON stated her process for training staff to enter orders accurately and in a timely manner started with new staff being provided a guidebook for the facility's EMR. She stated she did one on one training with nurses to ensure they knew how to enter orders into the system. The DON stated the facility was small, and they also supported each other with a lot of internal communication. The DON stated she had a monitoring process to ensure the orders were properly entered, but the facility was short an overnight nurse, and the assistant DON, who usually did the oversight for that issue, had been working the overnight shift. The DON stated when she did a root cause analysis of the failure to enter Resident #30's new orders, she determined the usual process had been fragmented, because the assistant DON was doing someone else's job. The DON stated the other issue she determined was that LVN A was distracted during the process, which could happen often at the nurse's station. The DON stated a potential negative impact would be related to blood sugars, which were running high, and there could be some damage to be done. During an interview on 08/02/23 at 12:51 PM, the ADM stated her expectation on new orders for residents being implemented was that the nurse immediately entered the data in the EMR so the MAR would be updated, and the order be followed. The ADM stated her expectation after that was that nurse management, who included the DON, assistant DON, and MDS nurse would reconcile all new orders entered into the EMR and ensure they were entered correctly. The ADM stated in the case of the order to increase Resident #30's insulin, she did not know why it did not happen. The ADM stated LVN A might have been on autopilot for some unknown reason. The ADM stated LVN A was usually very thorough. The ADM stated there were textbook outcomes that could occur if insulin was not increased as ordered, but everyone was different, so she could not say what the outcome could have been for Resident #30. Review of undated facility policy titled Medication Orders reflected the following: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists. Mail the appropriate copy of the telephone / verbal order form to the prescriber. 676399 Page 2 of 3 676399 08/02/2023 San Saba Nursing & Rehabilitation 2400 West Brown Street San Saba, TX 76877

F 0684 Procedure: Level of Harm - Minimal harm or potential for actual harm Documentation of the medication order Residents Affected - Few 1. Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order sheet, or the telephone order sheets (if it is a verbal order) and the Medication Administration Record (MAR). 2. The following steps are initiated to complete documentation: $ Clarify the order $ Enter the orders on the medication order and receipt record $ Call (or fax) the medication order to the provider pharmacy $ Transcribe newly prescribed medications on the MAR or treatment record. When a new order changes the dosage of a previously prescribed medication, discontinue previous entry by writing ?DISCONTINUED on the MAR. Enter the new order on the MAR as a separate entry with arrows drawn to the start date. Specific Procedures for the four types of medication orders 1. NEW HANDWRITTEN ORDERS signed by the prescriber. The charge nurse on duty at the time the order is received, notes the order and enters it on the physician order sheet if not written there by the prescriber. If necessary, the order is clarified before the prescriber leaves the nursing station whenever possible. 676399 Page 3 of 3