MEMORIAL NURSING AND REHABILITATION CENTER

Based on observations, interviews, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts (Medication Cart-Hall200/300 and Medication cart 400/500) reviewed for medication storage. <BR/>The facility failed to ensure that there no lose pills, expired medications, and labels were legible.<BR/>-2.5 pills found in medication cart for Hall 200/300<BR/>-2 bottles of expired medications found in medication cart for Hall 400/500.<BR/>Findings included:<BR/>Observation on 05/13/24 at 09:15 AM revealed Medication cart for 200 and 300 Hall. 2.5 pills were found in the bottom of medication cart drawer, 1 pill was identified as Duloxetine and the 2nd was identified as Aspirin, and the 1/2 pill was unidentifiable by MA. <BR/>Observation on 05/13/24 at 09:39 AM revealed the medication cart for Hall 400 and 500 revealed Resident 86's stool softener with an expiration date of 04/2024 and a bottle of Vitamin D3 had an expiration date of May 2023. MA did confirm that Resident #86 did receive the Vitamin D this morning. <BR/>During an interview on 05/13/24 at 09:59 AM MA stated that a negative outcome for administering expired medications would be that the medication would not be as effective. MA stated that a negative outcome for having lose pills in the bottom of the medication cart drawers could possibly lead to a missed dose. <BR/>During an interview on 05/15/24 at 02:09 PM ADON stated that a negative outcome for administering expired medications would be that the medication was not as potent. ADON also stated that lose pills found in the medication cart drawers it could lead to missed doses for residents later. <BR/>During an interview on 05/15/24 at 02:12 PM LVN stated that a negative outcome for administering expired medication would be that the medication is less effective. LVN stated that the negative outcome for finding lose pills in the medication cart drawers was you don't know who they belong to, and this could cause issues later on. <BR/>During an interview on 05/15/24 at 02:14 PM DON stated that a negative outcome for administering expired medications was they could have a negative effect on our residents and the medication will not be effective for them. DON stated that a negative outcome for finding lose pills in the medication cart drawers could lead to residents not possibly having the dose that the resident may need and could lead to a missed dose. <BR/>Record review of facility provided policy titled, Storage of Medications, reviewed 03/2021, revealed the following:<BR/>Policy Statement: <BR/>Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.<BR/> .f. Medications labeled for individual residents are stored separately from the floor stock medications when not in the medication cart. Private pay OTC brought in by family will be properly. Labeled for resident and stored in med cart. <BR/> .l. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal (section I.E), and reordered from the pharmacy (Section I.C.2), if a current order exists.<BR/>Record review of facility provided policy titled, The Medication Labels, dated 09/2014, revealed the following:<BR/> .8. Medication containers have soiled, damaged, incomplete, illegible, confusing, or makeshift labels are returned to the dispensing pharmacy for relabeling or destroyed in accordance with the medication destruction policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for one of 14 (Resident #3) residents reviewed for DNR orders.<BR/>Resident #3 had an OOH-DNR order that was not completed as it was not signed or dated by a physician. <BR/>These failures could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences.<BR/>Findings include:<BR/>Record review of Resident #3's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), chronic kidney disease (damaged kidneys that are unable to filter blood appropriately), schizophrenia (serious mental disorder in which people abnormally interpret reality), and hypertension (high blood pressure).<BR/>Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 03 out of 15 which indicated his cognition was severely impaired. He required total dependence with one-person assistance with bed mobility and personal hygiene, total dependence with two-person assistance with transferring and toilet use, extensive one-person assistance with dressing, and supervision with set-up help with eating. <BR/>Record review of Resident #3's care plan, dated [DATE], revealed, in part:<BR/>Code Statue DNR .Family desires to continue DNR .<BR/>Record review of Resident #3's physician's orders revealed, in part:<BR/>Code Status: DO NOT RESUSCITATE, dated [DATE].<BR/>Record review of Resident #3's chart revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 2A Patient's Statement: I, the undersigned, am capable of making an informed decision regarding the withholding or withdrawing of CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued. Cardiopulmonary resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation . Section 2A revealed Resident #3's signature. There was no printed or typed name for Resident #3 or date in Section 2A, the lines for these were left blank. Section 4 revealed PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no physician signature, physician printed name, license number or date in this section; the lines were left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no physician signature listed on the line that read, Signature of Attending Physician.<BR/>During an interview on [DATE] at 11:23 AM, SW confirmed she assisted residents with completing DNR orders. She stated that Section 4, Physician's Statement should have been completed for Resident #3's DNR order, and it would have been best for the resident's printed name and date to have been completed as well in Section 2A, Patient's Statement. SW stated if the physician statement section was not completed, the physician may not have been in the loop with what the resident's medical wishes were. SW stated if there was some sort of conflict or question among the resident's family regarding the resident's end-of-life wishes, if the resident did not have his faculties, the physician may not have been able to support the resident's wishes. With the DNR order not being signed by the physician, in an emergent situation, SW stated, depending on who was caring for the resident that day, there could have been question about what the resident's end-of-life wishes were and there could have been the potential for him not having his medical wishes being met (to initiate emergency treatment or not). SW confirmed that she had attended training regarding DNR orders before; she stated that since she was not a lawyer, she was told she could not fill DNR orders out for residents, but she did do the running for them to assist with getting the appropriate signatures. When asked what she would have done if she received an OOH DNR that was not fully completed for a newly admitted resident, she stated she would have had the resident or resident family complete a new one.<BR/>Record review of facility provided policy titled, Advanced Care Planning Patient Self-Determination Act, dated [DATE], revealed, in part:<BR/>Policy Statement: [facility name] respects the right of competent individuals or their designated representatives to control decisions related to their medical care in accordance with state law. Competent residents have the right to execute and document advanced directives, such as a Living Will or Health Care Power of Attorney.<BR/>It is the policy of [facility name] to honor Advanced Directives which are properly executed in accordance with state law.<BR/>A patient's attending physician has primary responsibility for directing the care of the patient. No request for the rendering, withholding, termination of treatment and cares will be honored by the facility without a physician's order.<BR/>Rules:<BR/> .B. State Law<BR/>[Facility name] social worker or designee will review the resident's advanced directive. This review will not <BR/>constitute a representation that such advanced directive complies with requirements of state law. The facility <BR/>will comply with the requirements of state law governing advanced directives. <BR/>C. Documentation<BR/> .3. Advanced Directive are written documents that state choices for health care/or names someone to <BR/>make those choices. These may include:<BR/>a. Out of Hospital Do Not Resuscitate Order<BR/> .G. Request by Resident to Execute and [sic] Advanced Directive<BR/>Social worker will assist the resident or resident representative in obtaining the appropriate forms and <BR/>referrals.<BR/>Record review of facility provided document titled, Frequently Asked Questions about Advanced Care Planning, undated, that was provided to residents upon admission, revealed, in part:<BR/> .Other Questions about Hospitals and Nursing Facilities and Treatment at the End of Life<BR/> .What is an Out-of-Hospital Do Not Resuscitate Order (OOHDNR)?<BR/>This form is for use when you are not in the hospital. It lets you tell health care workers, including Emergency Medical Services (EMS) workers, NOT to do some things if you stop breathing or your heart stops. If you don't have one of these forms filled out, EMS workers will ALWAYS give you CPR or advanced life support even if your advance care planning forms say not to. You should complete this form as well as the Directive to Physicians and Family or Surrogates and the Medical Power of Attorney form if you don't want CPR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for one of 14 (Resident #3) residents reviewed for DNR orders.<BR/>Resident #3 had an OOH-DNR order that was not completed as it was not signed or dated by a physician. <BR/>These failures could place residents with DNR orders at risk for receiving, or not receiving, life-saving measures that align with their medical preferences.<BR/>Findings include:<BR/>Record review of Resident #3's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), chronic kidney disease (damaged kidneys that are unable to filter blood appropriately), schizophrenia (serious mental disorder in which people abnormally interpret reality), and hypertension (high blood pressure).<BR/>Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 03 out of 15 which indicated his cognition was severely impaired. He required total dependence with one-person assistance with bed mobility and personal hygiene, total dependence with two-person assistance with transferring and toilet use, extensive one-person assistance with dressing, and supervision with set-up help with eating. <BR/>Record review of Resident #3's care plan, dated [DATE], revealed, in part:<BR/>Code Statue DNR .Family desires to continue DNR .<BR/>Record review of Resident #3's physician's orders revealed, in part:<BR/>Code Status: DO NOT RESUSCITATE, dated [DATE].<BR/>Record review of Resident #3's chart revealed a document titled TEXAS DEPARTMENT OF HEALTH STANDARD OUT-OF-HOSPITAL DO-NOT-RESUSCITATE ORDER, dated [DATE], which revealed in Section 2A Patient's Statement: I, the undersigned, am capable of making an informed decision regarding the withholding or withdrawing of CPR, including the treatments listed below, and I direct that none of the following resuscitation measures be initiated or continued. Cardiopulmonary resuscitation (CPR), Transcutaneous Cardiac Pacing, Defibrillation, Advanced Airway Management, Artificial Ventilation . Section 2A revealed Resident #3's signature. There was no printed or typed name for Resident #3 or date in Section 2A, the lines for these were left blank. Section 4 revealed PHYSICIAN'S STATEMENT: I, the undersigned, am the attending physician of the patient named above. I have noted the existence of this order in the patient's medical records, and I direct out-of-hospital heath care professionals to comply with this order as presented. There was no physician signature, physician printed name, license number or date in this section; the lines were left blank. The last section of the document revealed, ALL PERSONS WHO SIGNED MUST SIGN HERE: This document has been properly completed. There was no physician signature listed on the line that read, Signature of Attending Physician.<BR/>During an interview on [DATE] at 11:23 AM, SW confirmed she assisted residents with completing DNR orders. She stated that Section 4, Physician's Statement should have been completed for Resident #3's DNR order, and it would have been best for the resident's printed name and date to have been completed as well in Section 2A, Patient's Statement. SW stated if the physician statement section was not completed, the physician may not have been in the loop with what the resident's medical wishes were. SW stated if there was some sort of conflict or question among the resident's family regarding the resident's end-of-life wishes, if the resident did not have his faculties, the physician may not have been able to support the resident's wishes. With the DNR order not being signed by the physician, in an emergent situation, SW stated, depending on who was caring for the resident that day, there could have been question about what the resident's end-of-life wishes were and there could have been the potential for him not having his medical wishes being met (to initiate emergency treatment or not). SW confirmed that she had attended training regarding DNR orders before; she stated that since she was not a lawyer, she was told she could not fill DNR orders out for residents, but she did do the running for them to assist with getting the appropriate signatures. When asked what she would have done if she received an OOH DNR that was not fully completed for a newly admitted resident, she stated she would have had the resident or resident family complete a new one.<BR/>Record review of facility provided policy titled, Advanced Care Planning Patient Self-Determination Act, dated [DATE], revealed, in part:<BR/>Policy Statement: [facility name] respects the right of competent individuals or their designated representatives to control decisions related to their medical care in accordance with state law. Competent residents have the right to execute and document advanced directives, such as a Living Will or Health Care Power of Attorney.<BR/>It is the policy of [facility name] to honor Advanced Directives which are properly executed in accordance with state law.<BR/>A patient's attending physician has primary responsibility for directing the care of the patient. No request for the rendering, withholding, termination of treatment and cares will be honored by the facility without a physician's order.<BR/>Rules:<BR/> .B. State Law<BR/>[Facility name] social worker or designee will review the resident's advanced directive. This review will not <BR/>constitute a representation that such advanced directive complies with requirements of state law. The facility <BR/>will comply with the requirements of state law governing advanced directives. <BR/>C. Documentation<BR/> .3. Advanced Directive are written documents that state choices for health care/or names someone to <BR/>make those choices. These may include:<BR/>a. Out of Hospital Do Not Resuscitate Order<BR/> .G. Request by Resident to Execute and [sic] Advanced Directive<BR/>Social worker will assist the resident or resident representative in obtaining the appropriate forms and <BR/>referrals.<BR/>Record review of facility provided document titled, Frequently Asked Questions about Advanced Care Planning, undated, that was provided to residents upon admission, revealed, in part:<BR/> .Other Questions about Hospitals and Nursing Facilities and Treatment at the End of Life<BR/> .What is an Out-of-Hospital Do Not Resuscitate Order (OOHDNR)?<BR/>This form is for use when you are not in the hospital. It lets you tell health care workers, including Emergency Medical Services (EMS) workers, NOT to do some things if you stop breathing or your heart stops. If you don't have one of these forms filled out, EMS workers will ALWAYS give you CPR or advanced life support even if your advance care planning forms say not to. You should complete this form as well as the Directive to Physicians and Family or Surrogates and the Medical Power of Attorney form if you don't want CPR.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (the ICP) of 5 staff observed for resident care. <BR/>-The ICP (Infection Control Preventionist) failed to clean the glucometer machine (an instrument for measuring the concentration of glucose in the blood) between resident use. <BR/>This deficient practice has the potential to affect residents in the facility receiving diabetic care by exposing them to care that could lead to the spread of viral infections, secondary infections, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. <BR/>Findings include: <BR/>During an observation on 04/03/23 at 11:57 AM the ICP performed a blood sugar test on Resident #10. The ICP did not clean the glucometer machine (an instrument for measuring the concentration of glucose in the blood) prior to testing Resident #10's blood. The ICP then docked the glucometer machine to transmit the result to the pharmacy. The ICP then removed the glucometer machine from the docking station and tested Resident #20's blood sugar, then the ICP redocked the glucometer machine without cleaning it. <BR/>During an interview on 04/03/23 at 12:02 PM the ICP reported that she did not clean the glucometer machine between testing Resident #10, Resident #20, and before docking the glucometer machine after testing the last resident. The ICP verified that the glucometer machine did need to be cleaned. The ICP reported that if the glucometer machine is not cleaned properly then cross contamination can result between residents. The ICP verified that it is her responsibility to educate all nursing staff on infection control and prevention. <BR/>During an interview with 04/05/23 at 09:59 AM the DON reported that when staff complete blood sugar testing they should complete hand hygiene and they should clean the glucometer machine between each residents testing. The DON reported that if staff do not clean the glucometer machine between each resident testing, then staff can spread infection from blood or other sources because you do not know what else is in a resident's room.<BR/>Record review of the facility provided policy titled Infection Control amended 12-28-2021 revealed the following:<BR/>Rules:<BR/>5. All resident equipment will be sanitized by the staff when used with an approved germicidal before and after use, such as but not limited to<BR/>-Blood Glucose Monitors. <BR/>Record review of the facility provided training titled Accu-Check Inform II MNRC Training Checklist undated revealed the following:<BR/>-Clean with Oxivir 1 Wipes daily, between each patient, and after every use.