Health inspection·September 10, 2024

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 closed medical record review, review of the wound nurse practitioner (NP) progress notes, and interviews the facility failed to ensure wound notes were accurately documented to reflect current treatment orders for skin alterations. This affected one resident (#1) of three record reviewed. Findings included: 1. a. Closed medical record revealed Resident #1 was admitted to the facility initially on 03/07/24 and re-admitted on [DATE] with diagnoses including tracheostomy, embolism and thrombosis of deep veins of left upper extremity, acute respiratory failure, quadriplegia, dependence on respirator, and Raynaud's. Review of Resident #1's Wound NP #500's progress note dated 07/26/24 revealed new orders to cleanse the right scapula wound with 3% acetic acid. Review of Resident #1's orders revealed no evidence 3% acetic acid was ordered to cleanse the wound. Interview on 09/10/24 at 4:35 P.M., with the Director of Nursing (DON) and Wound Licensed Practical Nurse (WLPN) #224 revealed the facility never received the order for 3% acetic acid. The WLPN #224 and DON reported the Wound NP #500 gives staff verbal orders and the staff enter the orders into the electronic medical record. The DON reported some of the orders were signed by the Wound NP #500, however some were signed by the resident's physician. Interview on 09/10/24 at 4:45 P.M., with Wound NP #500 revealed she gets distracted and may have documented the order inaccurately and would probably go by the orders the staff had entered more likely. b. Review of Resident #1's Wound NP #500's progress note dated 07/26/24, 08/02/24, and 08/09/24 revealed the resident had venous ulcers on left lateral lower leg proximal and left lower leg distal. New orders written to wrap with ace bandages daily as tolerated. Review of Resident #1's orders revealed no evidence ace bandages to the lower extremities was ever ordered. Interview on 09/10/24 at 4:35 P.M., with the DON and WLPN #224 revealed the facility never received the order to wrap the lower legs with ace bandages daily. Page 1 of 2 365466 365466 09/10/2024 The Laurels of Heath 717 South 30th Street Heath, OH 43056

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/10/24 at 4:45 P.M., with Wound NP #500 revealed she gets distracted and may have documented inaccurately and would probably go by the orders the staff had entered more likely. The Wound NP #500 reported initially she wanted ace wraps but then determined it would not be beneficial. c. Review of Resident #1's Wound NP #500's progress note dated 08/02/24 revealed to cleanse the right head, right lateral calf, right and left scapula with 1/2 strength Dakin's solution. Review of Resident #1's orders revealed no evidence the 1/2 strength Dakin's solution was ordered. Interview on 09/10/24 at 4:35 P.M., with the DON and WLPN #224 revealed the facility never received the order for 1/2 strength Dakin's solution. Interview on 09/10/24 at 4:45 P.M., with Wound NP #500 revealed she gets distracted and may have documented inaccurately and would probably go by the orders the staff had entered more likely. d. Review of Resident #1's Wound NP #500's progress note dated 08/09/24 revealed to cleanse the sacrum with 1/2 strength Dakin's solution. Review of Resident #1's orders dated 08/09/24 revealed the order was changed to cleanse the sacrum wound with house wound cleanser. Interview on 09/10/24 at 4:35 P.M., with the DON and WLPN #224 revealed the resident's wound was originally being cleansed with Dakin's solution and the Wound NP #500 gave verbal orders on 08/09/24 to change to house wound cleanser. Interview on 09/10/24 at 4:45 P.M., with Wound NP #500 revealed she gets distracted and may have documented inaccurately and would probably go by the orders the staff had entered more likely. This deficiency represents incidental findings of non-compliance investigated under Complaint Number OH00156945. 365466 Page 2 of 2