Health inspection·July 2, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately document (breathing machine) refusals for one resident (R1) out of three residents reviewed for oxygen therapy in the sample of four. Findings include: The Resident Care Policy and Procedure dated 5/2022, documents It is the policy of this facility to maintain current physician orders to provide treatment according to the attending physician for each resident of the facility. a) All medications and treatments shall be given only upon the written order of the physician. All such orders shall be written in the medical record and shall be given as prescribed by the physician at the designated times. g) If for any reason, a physician's medication or treatment order cannot be followed, the physician shall be notified as soon as is reasonable, depending upon the situation, a notation of this will be made into the medical record. The Job Description for Licensed Practical Nurses dated 11/10/17, documents Essential Job Function: Responsible for nursing care of assigned residence in accordance with new nursing facility and nursing service policies and procedures. Chart medications and treatments according to procedure. R1's current Medical Record, documents R1 was admitted to the facility on [DATE] with diagnoses which included Primary Central Sleep Apnea and Chronic Obstructive Pulmonary Disease. R1's Physicians Order dated 2/10/23, at 11:08 AM, documents (Breathing machine) per home settings on at all times when sleeping or napping. R1's Care Plan dated 1/24/23, documents that R1 has chronic obstructive pulmonary disease and OSA (Obstructive Sleep Apnea). The intervention is that R1 will use a (breathing machine) as ordered when napping and in bed at night. On 6/30/23 at 9:55 AM, V2 (Director of Nursing) stated that V12 (R1's Family Member #1) complained that the (breathing machine) was not being used as ordered for R1, however the nursing documentation showed that the (breathing machine) was being used as ordered. V12 brought in a Sleep Therapy Report that showed the use of the (breathing machine). There were days that the report showed the (breathing machine) was not used and it did not match the facility Treatment Administration Records (TAR) documentation. There were also a couple of nursing notes written by V8 (Licensed Practical Nurse) that documented the (breathing machine) was used on her shift that did not match the Sleep Therapy Report. V8 was asked about the documentation and stated that she would check off the breathing machine task before she applied the machine to R1. When V8 went to R1's room to apply the (breathing machine) Page 1 of 2 146042 146042 07/02/2023 H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mask R1 would refuse the treatment sometimes, and V8 would forget to go back and change the documentation to show that R1 refused the treatment. V2 stated that an In-Service was done with all nurses about the (breathing machine) and correct documentation. On 6/30/23 at 12:30 PM, V2 (Director of Nursing) and V1 (Administrator) reviewed R1's Sleep Therapy Report previously provided by V12 (R1's Family Member #1) and compared it to the Treatment Administration Record (TAR) and agreed that the report indicated the (breathing machine) was not used by R1 on 6/05, 6/06, 6/20, and 6/21/23 On 6/30/23 at 1:35 PM, V1 (Administrator) stated that she is aware that the Therapy Report for R1's (breathing machine) that V12 (R1's Family Member #1) presented to the facility had days that there was no usage documented for R1. V1 was also aware that the Treatment Administration Record (TAR) and the Nursing Notes had documentation that R1 received the (breathing machine) treatment on days the Therapy Report showed the machine was not used. R1's Nursing Note dated 6/5/23 at 11:33 PM, documents (R1) Resting quietly Arouses easily voices no C/O (Complaints of) keeping (breathing machine) mask on this night. (R1's Sleep Therapy Report documents No usage for the (breathing machine) on 6/5/23.) R1's Nursing Note dated 6/6/23 at 22:07 PM, documents (R1) Resting quietly Arouses easily voices no C/O keeping (breathing machine) mask on this night. (R1's Sleep Therapy Report documents No usage for the (breathing machine) on 6/6/23.) On 6/30/23 at 7:50 PM, V8 (License Practical Nurse) stated that she usually works the night shift from 6:00 PM to 6:00 AM, and she knows it is important for R1 to use her (breathing machine) when sleeping. V8 would mark off the task on the Treatment Administration Record (TAR) for the (breathing machine) before going in to apply the mask to R1. There were times that R1 refused to have the mask applied. V8 did not go back and correct the TAR to show that R1 refused the treatment. I am guilty about not thinking to change the documentation when R1 refused. V8 was asked about the nursing notes dated 6/5/23 and 6/6/23 that she wrote documenting that R1 had used the (breathing machine) during the night when she didn't. V8 stated I got in a hurry and copied and pasted the notes not paying attention to the details. I was wrong for doing that. Now I realize the information in the Nursing Notes are not correct. I know that's not a good excuse. There is no good excuses. R1's Sleep Therapy Report dated 5/31/23 - 6/29/23, documents that there were 16 days there was no usage recorded. This report was compared to R1's Treatment Administration Record (TAR) dated 6/1/236/30/23. There are four days (6/5, 6/6, 6/20, and 6/21/23) that there is no documentation charted that R1 was refusing the (breathing machine). V8 (Licensed Practical Nurse) worked on all four days from 6:00 PM 6:00 AM. On 7/1/23 at 9:20 AM, V1 (Administrator) stated that the information documented in the nursing notes should be accurate. V1 also stated that there is no policy on accurate documentation. 146042 Page 2 of 2