Texas Rehabilitation Hospital of Keller

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 28637 Based on interviews and record reviews, the facility failed to ensure the nursing staff developed and kept current a nursing care plan for each patient that reflected the nursing care to be provided to meet the patient’s needs for 1 (Patient #1) of five patients reviewed for dysphagia and aspiration risks. Patient #1 was identified on admission as high risk for silent aspiration and respiratory compromise with orders for aspiration precautions. The risks were not included in her Care Plan and no individualized nursing interventions were identified or documented to meet her needs. Findings included: Record review of Patient #1’s History and Physical Report dated 04/03/2026 reflected an 86-year-old female admitted to the facility on 04/03/2026 after hospitalization following a fall from a ladder at home. She had sustained injuries including right arm fractures, rib fractures, two fractured vertebrae and a brain hemorrhage and a recommendation was made for a cervical collar at all times. She was found to have dysphagia after failing swallow studies and was “ ...at HIGH risk for ongoing silent aspiration with all PO intake, placing the patient at increased risk for aspiration pneumonia, respiratory compromise/occlusion ...”. She received a PEG [percutaneous endoscopic gastrostomy] tube placement while hospitalized. Patient #1’s Admission Orders, dated 04/03/2026 included: -NPO [nothing by mouth] -Aspiration Precautions. Order Details: Elevate head of bed (HOB) 30-45 degrees, unless contraindicated; For bolus administration elevate HOB 90 degrees during feeding and for at least 1 hour after or according to provider order. -Oxygen Therapy. Order Details: Routine, Flow Rate (L/min): 4, SpO2 [oxygen saturation] goal 90% or greater, Nasal Cannula -Cervical Collar Application (C-Collar) Patient #1’s Rehabilitation Nursing Goals, dated 04/03/2026 reflected the following: Nursing Goal #1: Patient will verbalize pain levels that allow participation in the rehabilitation program. Nursing Goal #1 Intervention: Patient will receive pain medication prior to participating in therapy. Nursing Goal #1 Status: Initial. Nursing Goal #1 Date Met: 04/03/2026 Nursing Goal #2: Patient will maintain normal blood pressure and heart rate. Nursing Goal #2: Intervention: Monitor vital signs every shift and as needed. Nursing Goal #2 Status: Initial Nursing Goal #2 Date Met: 04/03/2026 No other nursing goals were included. During an interview and record review on 06/03/2026 at 2:25 PM, Staff D stated when a patient was on aspiration precautions, they received a speech therapy evaluation. She stated the head of the bed should be elevated whenever continuous or bolus feeding was in place. She stated Patient #1 wore a cervical collar and the head of her bed should have been elevated at least 30-45 degrees at all times. She stated other care including ensuring the patients were repositioned properly, stop any feeding during care, and maintaining oral care. She stated oxygen and suction with a yaunkar was placed in the room as well as oral swabs. Staff D stated new patient care plans began with the nursing assessment then, the following day, OT, PT, and ST. When asked to display Patient #1’s nursing Care Plan, Staff D displayed the clinical record which reflected the only goals listed were for pain and blood pressure. She stated the nurses selected a couple of key issues initially and her other precautions were addressed in her orders. During an interview and record review on 06/04/2026 at 12:25 PM, Staff K stated she had completed the admission assessment for Patient #1 and knew about her by reviewing her preadmission screening documents. She stated she was aware of Patient #1’s aspiration precautions. She stated the order to keep the head of the bed up was generated when the diagnoses were entered. Staff K demonstrated the process for entering initial Care Plan goals on the computer and stated, “we put in the goals, on this day, I did not put in aspiration goal or oxygen goals in and I should have.” She stated she selected pain with the interventions to assess pain and give medications in a timely manner, and vital signs to be monitored every shift. She stated they were supposed to prioritize the condition of the patient at the time of the assessment, and at that time, Patient #1 had been in a lot of pain from her transfer. She stated the nurses could add to the goals throughout a patient’s stay Staff K stated she did write about the PEG tube and keeping the head of the bed up on the patient’s white board in her room, but she did not add the areas to her Care Plan. Record review of the facility’s policy and procedure titled, Assessment and Reassessment, dated 04/01/2021 reflected: POLICY “Patients are assessed upon admission and reassessed as needed in order to determine the appropriate care, treatment and services to meet the needs of the patient. PROCEDURE ...A complete assessment shall include physical, psychological, pain management, functional, visual and hearing, nutritional, spiritual needs, social status including social barriers such as language or culture, communication, educational and discharge planning ...The initial Nursing Assessment is completed on each patient by a Registered Nurse within twenty four (24) hours of admission, in order to assess the patient’s nursing care needs and obtain information for initiating the rehabilitation nursing plan of care; to identify patients who are at functional or nutritional risk; to determine potential discharge planning needs; and to orient the patient and family members to the Hospital environment and routine activities ...”.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 28637 Based on interviews and record reviews, the facility nursing staff failed to clarify medication orders that included an oral route of administration for two of two patients reviewed (Patient #1 and Patient #9) whose admission orders included Nothing by Mouth (NPO) and Aspiration Precautions; and for one of two patients (Patient #9). Based on interviews and record reviews, the facility nursing staff failed to clarify medication orders for two of two (Patient #1 and Patient #9) whose admission orders included Nothing by Mouth (NPO) and Aspiration Precautions. 1. Admission medication orders and medication administration records for Patient #9 reflected his medications were ordered to be administered orally despite his diagnosis of dysphagia (difficulty swallowing) and the presence of a PEG (percutaneous endoscopic gastrostomy) tube. Nursing staff reported crushing his medications and administering them via his PEG tube despite two of his medications had instructions reflecting “do not crush or chew”. 2. Admission medication orders and medication administration records for Patient #1 reflected his medications were ordered to be administered orally despite her diagnosis of dysphagia (difficulty swallowing) and the presence of a PEG (percutaneous endoscopic gastrostomy) tube. Findings included: Review of facility policy titled, “Medication Administration,” dated 04/01/2021 reflected the following: Policy “Medications are administered upon the order of physicians, dentists, or podiatrists, who are members of the medical staff, are authorized members of the house staff or have been granted clinical privileges to write such orders and under the guidelines of their respective scopes of practice .... B. The following policies govern administration of medication in this institution ...2. ... The individual administering a medication is aware of the following information concerning each medication before administration ...d. Route and frequency of administration ...h. Precautions i. Any contraindications that would preclude the administration of the medication ...4. The individual administering a medication discusses any unanswered, significant concerns about the medication with the patient’s physician or prescriber of the medication and/or healthcare staff providing care, treatment and services to the patient. The discussion is documented in the patient’s medical record ...”. 1. Record review of Patient #9’s History and Physical Report dated 05/22/2026 by Staff O reflected a 73-year-old male admitted to the facility on 05/22/2026 following hospitalization for acute stroke symptoms including left sided weakness, facial droop and slurred speech. CT angiography demonstrated acute thrombotic occlusion. He underwent a thrombectomy and was admitted to neurosurgical ICU. He reported intermittent chronic dysphagia (difficulty swallowing) and failed a formal swallow study requiring gastrostomy tube placement and ongoing SLP [speech language pathology]. “ ...Chief complaint R CVA [right cerebrovascular accident] with L [left] side weakness/paresthesia, Dysphagia, NPO ...”. Patient #9’s SLP [Speech Language Pathology] Inpatient Evaluation, dated 05/23/2026 and completed by Staff G reflected: “ ...Clinical Swallowing Exam Dysphagia Recommendations ... Diet Consistency Recommendation: NPO Liquid Viscosity Recommendation: NPO with alternate means of nutrition/hydration/medication Medications Swallow Recommendation: Through feeding tube Patient #9’s Nutrition Services Order, dated 05/22/2026 reflected “NPO” [nothing by mouth]. Patient #9’s Medication Orders dated 05/22/2026 ordered by Staff O and entered by Staff S included the following: -Jevity 1.5 [tube feeding] 237 milliliters 6 times a day for 8 hours GTUBE -metoprolol (Toprol-XL 25 milligrams oral tablet, extended release) 1 tab oral BID [twice a day] Order Comment: Look Alike / Sound Alike Do Not Crush or Chew -melatonin (melatonin 3 milligrams oral tablet) 2 tabs [tablets] Oral at bedtime -atorvastatin (atorvastatin 40 milligrams oral tablet) 1 tab Oral at bedtime -aspirin (aspirin 81 milligrams oral delayed release tablet) 1 tab Oral daily Order Comment: Do Not Crush or Chew -apixaban (apixaban 5 milligrams oral tablet) 1 tab Oral BID -acetaminophen (acetaminophen 650 mg oral tablet, extended release) 1 tab oral every 4 hours as needed -ibuprofen 200 milligrams 1 tab Oral BID -ibuprofen 800 milligrams 1 tab Oral BID -acetaminophen 650 milligrams Oral every 6 hours as needed for mild pain -diphenhydramine 25 milligrams Oral BID as needed for itching -docusate 100 milligrams Oral BID as needed for stool softening -dextromethorphan-guaifenesin 10 milligrams -100 milligrams /5 milliliters oral liquid 10 milliliters Oral every 4 hours as needed for cough -magnesium hydroxide/aluminum hydroxide/simethicone 200 milligrams - 200 milligrams -20 milligrams /5 milliliters oral suspension 30 milliliter Oral daily as needed for heartburn/indigestion - magnesium hydroxide (Milk of Magnesia 8% oral suspension 30 milliliters Oral daily as needed for constipation - ondansetron 4 milligrams 1 tab Oral every 8 hours as needed for nausea/vomiting Review of Patient #9’s Medication Administration Records dated 05/22/2026 through 06/04/2026 revealed the route of all medications administered by nursing staff was reflected as “Oral”. During an observation, interview and record review on 06/04/2026 at 3:34 PM, Staff T stated it was her second day caring for Patient #9. She stated Patient #9 was at risk for aspiration and so all of his medications were crushed and given through his PEG tube. Staff T displayed Patient #9’s Medication Administration Record on her computer and stated she did not know why his medications were entered as oral. She stated, “we can’t give him medications orally” and, to her knowledge, everyone had been administering his medications through his tube. Staff T stated the medications containing the instructions ‘Do not crush or chew’ were crushed as well because Patient #9 was unable to swallow pills. She stated she had not contacted the physician for any medication order clarifications. She stated crushing delayed or extended-release medications could result in the patient receiving the whole dose at one time rather than over time. During an interview on 06/05/2026 at 8:29 AM, Staff O stated he believed Patient #9’s orders were entered incorrectly based on transfer orders received from his previous facility. He stated, “The nurses look at the patient, see the PEG, they let us know and we see and correct it.” He stated the orders should have been checked by the nurses and the pharmacy usually reported it as well. Staff O stated Patient #9 never received anything by mouth and there was signage in his room indicating he was NPO. When asked about staff crushing delayed or extended-release medications, Staff O stated usually the pharmacy reported the issue and recommended changes. He stated the risk of crushing medications was they could lose their effectiveness during the day. During a telephone interview on 06/05/2026 at 11:41 AM, Staff S stated, when entering medication orders and conducting medication reconciliation, he looked to see if the ordered medications were in stock, dose appropriate, whether there were any drug interactions, and checked the discharge orders to see what they could provide. He stated the route of administration was usually written in the transfer orders such as PO, IV, or suppository. He stated if the previous hospital had changed the route, the nurse would usually tell them and put the order in. He used the orders he was provided for Patient #9. 2. Record review of Patient #1’s History and Physical Report dated 04/03/2026 reflected an 86-year-old female admitted to the facility after hospitalization following a fall from a ladder at home. She had sustained injuries including right arm fractures, rib fractures, two fractured vertebrae and a brain hemorrhage. She was found to have dysphagia after failing swallow studies and was “ ...at HIGH risk for ongoing silent aspiration with all PO intake, placing the patient at increased risk for aspiration pneumonia, respiratory compromise/occlusion ...”. She received a PEG tube placement while hospitalized. Patient #1’s admission orders dated 04/03/2026 included the following: NPO and Aspiration Precautions. Medication orders included: Multivitamin 1 tab Oral daily Ondansetron 4 milligrams Oral every 8 hours as needed for nausea/vomiting Magnesium hydroxide 30 milliliters Oral as needed for constipation Hydralazine 25 milligrams Oral 1 tab every 6 hours as needed for hypertension All other medication orders reflected they were to be administered via PEG tube. Patient #1’s Medication Administration Record dated 04/03/2026 through 04/05/2026 revealed all medications were signed as administered via PEG or G-tube except: Multivitamin 1 tab Oral on 04/04/226 at 10:11 AM signed as administered by Staff K. During an interview and record review on 06/04/2026 at 11:36 AM, Staff D displayed Patient #1’s medication orders that reflected medications were ordered oral including a multivitamin tablet oral ordered daily, milk of magnesia PRN, ondansetron PRN; and hydralazine PRN. The orders had been entered by a pharmacist. Review of the medication administration record reflected a multivitamin was signed as administered orally. She stated either the pharmacist, or the charge nurse entered the orders, and it was everyone’s responsibility to ensure the medications were ordered and entered correctly and the pharmacist should have caught it. During an interview and record review on 06/04/2026 at 12:25 PM, Staff K stated she had completed the admission assessment for Patient #1 and was aware of her aspiration precautions. She stated she had not reviewed the initial medication orders and that another nurse had sent them on to the pharmacy. Staff K reviewed Patient #1’s Medication Administration Record and stated she had never given any medications to Patient #1 by mouth. She stated she believed the computer had automatically defaulted her dose route to “oral” but she stated she gave the medication through her PEG tube. She stated she was aware of Patient #1’s feeding tube prior to her arrival at the facility and knew the patient could not have anything by mouth. During an interview and record review on 06/04/2026 at 12:33 PM, Staff L stated the order for Patient #1’s multivitamin had been entered incorrectly as oral on 04/03/2026 then corrected the following morning on 04/04/2026. She stated they attempted to catch any medication order issues upon admission. She stated she was not aware of the other PRN medications that reflected a route of “oral”. During an interview and record review on 06/05/2026 at 8:40 AM, Staff P reviewed Patient #1’s clinical record on her computer and stated she did not see the patient, but her Resident did. She stated the nurses entered all the admission orders. When asked about the medications ordered as oral, Staff P reviewed the record and stated those were facility standing orders and may have been initially overlooked on admission. She stated she believed the nurses were cognizant enough not to give anything by mouth to a patient who was NPO or had a PEG tube. She stated she would typically tell them to go back and change everything to PEG for medication. She stated she usually told the nurses to tell the pharmacy to change medications to tube administration. She stated the orders came to them to cosign them and that was when they reviewed them. She stated, “I may not have caught those, usually the night shift lets us know.” During an interview on 06/05/2026 at 11:47 AM, Staff D stated she had assisted with Patient #9’s admission and was unaware that his medication routes had been entered as ‘oral’ until 06/04/2026 after surveyor questioned it. She stated she had helped Patient #9 get situated in his room and assisted with the initial screenings. Staff D stated that when a patient was admitted to the facility, the admitting nurse received a packet, and the patient’s medication orders were sent to the pharmacy. She stated the Charge Nurse usually entered everything except the medications into the computer. She stated the medications were reconciled by the pharmacist then were considered “good to go” meaning the medications could be released and accessed faster. She stated the medication orders entered a kind of “limbo” until they were reconciled. She stated the facility had standard PRN [as needed] orders which were also activated by the pharmacy such as those for Patient #1. Staff D stated everyone was responsible for ensuring a safe route of administration was entered in orders including the pharmacy and the physician. She stated the nurse was responsible for clarifying any orders that needed it with the physician including those that could not be crushed. She provided a list of medications that could not be crushed and stated the list was available on the Pyxis [medication dispensing machine] and the orders already reflected “do not crush or chew’. Staff D stated, “That’s where I, as a nurse, should be saying, ‘hey, can I get a clarification on this?’””