HARLINGEN, TX- TREASURE HILLS HEALTHCARE AND REHABILITATION CENTER

Treasure Hills Healthcare and Rehabilitation Center Registered Nurses hours per resident per day is 8 minutes. Almost 1/5 the national average. 

According to Medicare.gov, staffing rating is 1/5 stars. 

Controlled Substance Record

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** 41761

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, administration of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #33) reviewed for pharmaceutical services, in that:

The facility did not complete the Individual Resident’s Controlled Substance Record with resident’s name, resident ID#, room #, nor physician’s name for an order of Lorazepam 1mg tablet (Controlled substance) for Resident #33. This failure could affect residents receiving medications and could lead to medication errors.

Record review of Resident #33’s Admission Record dated 03/11/22 indicated Resident #33 was a [AGE] year-old female and was admitted to facility on 06/22/21 with diagnoses of end stage renal disease (kidney), bradycardia (slow heartrate), Type 2 Diabetes, hypertension (high blood pressure), anxiety disorder, skin cancer of nose, dementia, chronic kidney disease, amputation of left leg below the knee, amputation of right leg below the knee

Record review of Resident #33’s Quarterly MDS dated [DATE], indicated;
-BIMS score was 15 (cognitive status independent, decisions consistent/reasonable)
-required extensive assistance by two persons for bed mobility, transferring, dressing, toilet use and bathing
-resident with a condition or chronic disease that may result in a life expectancy of less than 6 months.

Review of Resident #33’s Individual Resident’s Controlled Substance Record revealed a date of 03/07/22 for Lorazepam 1 mg tablet Give 1 tablet by mouth at bedtime. The form indicated 1 tablet was given on 03/07/22 at 07:00 p.m , and 15 tablets were received with 14 remaining. Resident’s name, ID#, Room #, nor Physician is filled out on the Individual Resident’s Controlled Substance Record.

Observation of the Medication Aide Cart for 100 Hall on 03/08/22 at 12:00 p.m., with CMA 8 revealed 1 of 6 medications sheets was without a name, resident ID #, Room #, nor Physician’s name on it. Lorazepam 1 mg tablet Give 1 tablet by mouth at bedtime. Medication bottle in cart has Resident #33’s name on it.

In an interview 03/08/22 at 12:00 p.m., CMA 8 stated resident’s name should be on med sheet. She (nurse) didn’t do it. CMA 8 did not know who the receiving nurse was.

In an interview on 03/08/22 12:25 p.m., with LVN 1 stated when a medication comes in from pharmacy and if it was a controlled substance, the nurse receiving the medication was the one who fills in all the information. LVN 1 stated she did not know who the receiving nurse was.

In an interview on 03/09/22 10:55 a.m., with the DON stating, Pharmacy delivers medications and the nurse who has the resident who receives medication is responsible for getting the sheet ready for the resident with the name of resident and order written on it.