Health inspection·October 31, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record reviews and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #3) of 3 residents reviewed for pharmaceutical services. The facility failed to properly administer medication to Resident #3. This failure could place residents at risk of not receiving the therapeutic effect of their medications as ordered by physician. Findings included: Record review of Resident #3's admission Record dated 10/30/23 reflected a [AGE] year old male, admitted on [DATE] with diagnoses of Tracheostomy Status (procedure to help air & oxygen reach the lungs by making an opening into the windpipe from outside neck), Dependence on respirator [ventilator] status, Esophageal obstruction (medical emergency caused by obstruction of esophagus by swallowing a foreign body) Encephalopathy (disease that affects the whole brain, changes how it works), Personal history of sudden cardiac arrest (heart suddenly stops pumping), Dysphagia oropharyngeal (difficulty swallowing), Unspecified protein-calorie malnutrition, and Other speech disturbances. Record review of Resident #3's Care plan, date initiated 4/18/23, revealed Resident #3 required feeding tube r/t esophageal stricture, subdural hematoma, dysphasia. Record review of Resident #3's MDS dated [DATE] revealed Resident #3 Severely Impaired and had a BIMS Score of 99 indicating resident was unable to complete review. Record review of Resident #3's Physician Orders revealed; order summary start date 10/19/23: Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 MG (Acetaminophen) Give 1 tablet via PEG-Tube two times for arthritic pain. Record review of Resident #3's MAR dated October 2023 revealed Tylenol 8 Hour Arthritis Pain Oral Tablet Extended Release 650 MG was administered to Resident #3 on 10/19/23, 10/20/23, 10/21/23, 10/22/23, 10/23/23, 10/24/23, 10/25/23, 10/26/23, 10/27/23. Interview on 10/30/23 at 9:52 am LVN D said she had administered the Tylenol ER to Resident #3 via peg-tube. She said she dissolved the medication in water prior to giving it to him. LVN said that she dissolved it because she needed to administer it via Resident #3's peg tube. She said that the Page 1 of 2 676414 676414 10/31/2023 Mid Valley Nursing & Rehabilitation 601 N Mile 2 West Mercedes, TX 78570

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medication was effective when it was dissolved. She also said she did not ask Resident #3's physician nor did she ask the facility DON if she could dissolve it. LVN D said she did not observe complaints of pain by Resident #3 when given this medication LVN D said that Resident #3 was receiving Tylenol 3 PRN. Interview on 10/30/23 at 2:58 pm LVN M said she had administered the Tylenol ER to Resident #3 via peg-tube. She said that type of medication should not be crushed because it will not work the way it's supposed to. She said it loses the ability to release the contents the way was supposed to be released to the body. LVN M said dissolving it is somewhat effective like Tylenol but not extended. She said she monitored Resident #3 for signs of pain as he was non-verbal, after administering and also asked Resident #3's family member as she was at bedside most of the time. She was able to let staff know if he is in pain and she had not brought up concerns. Interview on 10/30/23 at 4:22 pm RN A said she had dissolved Resident #3's Tylenol ER tablets in water. RN A said that she did not consult with the physician prior to doing it. She said since the medication was not a new medication, it wasn't an initial dose and Resident #3 was already receiving it, she administered it that way. She said it could possibly be less effective if dissolved but was monitoring Resident #3 for signs of pain. Interview on 10/30/23 at 4:46 pm the DON said that extended-release medication should not be administered via peg tube. She said that Tylenol ER was being administered to Resident #3 and should not have been and was discontinued once it was brought up to her attention by LVN M. She said LVN M was asked about dissolving the medication by a surveyor and she then discussed it with her. When asked if crushing or dissolving this type of medication would be effective as it was recommended, DON only replied that it would not be as effective. She did not give a response as to why it would not be, when asked. Record review of policy requested on medication administration for peg tube residents did not specifically include verbiage on crushing and dissolving medication. Record review of the manufacturer's directions for use of Tylenol 8 HR Arthritis Pain for Extended Release Arthritis & Joint Pain Relief, 650mg Acetaminophen: -take 2 caplets every 8 hours with water -swallow whole; do not crush, chew, split, or dissolve 676414 Page 2 of 2