Health inspection·February 26, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Few Based on closed record review, hospital visit summary review, hospital discharge summary review, review of drainage guidelines for the PleurX, (a thin, flexible tube that's placed in your chest to drain fluid from your pleural space, to make it easier to breathe) and interview, the facility failed to provide necessary and adequate care for Resident #60 who had a PleurX chest tube. The facility failed to ensure nursing staff were properly educated on the tube and failed to ensure the PleurX chest tube was routinely monitored, assessed (for proper placement), monitored for signs/symptoms of infection, accessed, and drained. This affected one resident (#60) of one resident reviewed for chest tubes. The facility census was 58. Findings Include: Review of the closed medical record for Resident #60 revealed an initial admission date of 01/16/25 with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), edema, depression, insomnia, malignant neoplasm of female breast, shortness of breath, anemia, psychoactive substance abuse and congestive heart failure. The resident was discharged on 01/21/25 to an acute care hospital and did not return to the facility. Review of the resident's acute care hospital discharge summary on 01/16/25 revealed the resident had Stage IV breast cancer with malignant effusions, brain, bone and soft tissue metastatic cancer. The resident had a PleurX (chest tube) placement on 11/15/24 per interventional pulmonary. The assessment indicated the PleurX chest tube placement was to manage the resident's respiratory symptoms caused from the malignant effusions. Review of the resident's admission assessment dated [DATE] revealed no assessment addressing the PleurX placement to the resident's chest. Review of the progress note dated 01/16/25 at 8:46 A.M. revealed Resident #60 was admitted from the hospital due to shortness of breath and COPD and was on four liters of oxygen via nasal cannula with a history of breast cancer without both breasts. Further review revealed the PleurX drain was not addressed. The assessment and plan included the resident had malignant tumor of breast with metastases to bone, brain, soft tissue, pleural effusions, status post PleurX placement on 11/15/24 with complications. PleurX capped and pulmonary recommended draining intermittently for shortness of breath. The resident's respirations were documented to be even and unlabored. Review of the Nurse Practitioner's (NP) progress note dated 01/17/25 revealed the resident was Page 1 of 3 365933 365933 02/26/2025 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few status post PleurX placement on 11/15/24 and recommended draining intermittently for shortness of breath. The progress note recommended to continue oxygen at two liters per nasal cannula. The progress note indicated the resident had no shortness of breath at this time. Review of the progress note dated 01/17/25 at 11:29 A.M. revealed the resident left the facility for a funeral at 9:00 A.M. The progress note indicated the resident's respirations were even, unlabored and she continued on oxygen continuously. Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident required substantial/maximal (staff) assistance with toileting, showers, dressing, transfers and set-up/supervision with eating. The assessment indicated the resident was frequently incontinent of both bowel and bladder. Review of the resident's plan of care revealed no care plan addressing the use of the PleurX chest drain or the potential for infection. Review of the resident's physician orders revealed no physician orders were in place for the care of the PleurX drain during the resident's stay. Review of the care conference form dated 01/21/25 revealed the form was blank. Review of the progress note dated 01/21/25 at 4:40 P.M., revealed the resident had the PleurX drain, however had no drain kit to implement the use of the PleurX. The progress note indicated the resident was short of breath at this time. Review of a situation background assessment recommendation (SBAR) summary dated 01/21/25 at 7:40 P.M. revealed the resident had shortness of breath at the time of the evaluation. The assessment documented the resident's shortness of breath began that afternoon. The resident's vital signs were as follows, blood pressure 98/72 (hypotensive), temperature 97.6, pulse 108, respirations 18 and oxygen saturation rate was 98% with an unspecified liter of oxygen in place via nasal cannula. Review of the respiratory status evaluation contained in the SBAR revealed the resident had shortness of breath and had progressive or persistent shortness of breath. The summary indicated the resident was sent to the local emergency room (ER). Review of the hospital documentation dated 02/01/25 (a discharge summary) revealed Resident #60 was admitted from the extended care facility (ECF) on 01/21/25 with past medical history including breast cancer with metastasis to the brain, bone, and soft tissue, malignant left pleural effusion with PleurX catheter, COPD, and chronic respiratory failure who presented from the ECF with recurrent pleural effusion. The resident reported since her discharge to the ECF on 01/16/25 her PleurX had not been drained (by staff at the ECF). The resident had acute on chronic hypoxic respiratory failure and baseline used two liters of oxygen, however since the draining of the PleurX (in the hospital) she was only requiring one liter of oxygen. The resident was also found to have bilateral lower lobe pneumonia and completed a course of antibiotics during the hospital stay. Resident #60 was status post left PleurX placement on 11/15/24 followed with pulmonology and recommendations against suctioning or hooking up to chest tube; however, it was recommended to intermittently drain catheter on Monday, Wednesday, and Friday. Resident #60 reported that her PleurX had not been drained at the ECF. Resident #60 was transferred to palliative floor while staff worked on discharging her home with hospice services. 365933 Page 2 of 3 365933 02/26/2025 Buckeye Terrace Rehabilitation and Nursing Center 140 N State Street Westerville, OH 43081

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 02/14/25 at 2:33 P.M., an interview with Regional Director of Clinical Services (RDCS) #455 confirmed the resident had no assessment, monitoring, respiratory assessment or physician's orders for the care of the PleurX chest tube. She verified staff had not been trained on the use of the PleurX chest tube. Review of the drainage guidelines for the PleurX Catheter System revealed the catheter was to be inspected daily, change the dressing regularly, at least once a week and as needed when it becomes loose, wet or dirty and follow your healthcare provider's instructions for draining the fluid from your pleural space. The deficient practice was corrected on 01/29/25 when the facility implemented the following corrective actions: • On 01/21/25 Resident #60 was sent out to the hospital for shortness of breath. • On 01/23/25 the facility implemented a Quality Assurance and Performance Improvement Action Plan. The systemic plan was to complete a whole house skin check on all residents to identify anyone that had a medical device. Those residents identified with an implanted medical device were reviewed to ensure care orders were in place. The Director of Nursing (DON) and Wound Nurse #151 were educated by the RDCS #455 on ensuring orders are being transcribed from the hospital after visit summary for implanted medical devices. All licensed nursing staff were educated by the DON on ensuring orders are written timely from the hospital after visit summary for all implanted medical devices. Audits would be conducted on all newly admitted residents hospital after visit summary to ensure orders are transcribed for all implanted medical devices five times a week for eight weeks by the DON and/or designee. Audits will be conducted on all residents that have an implanted medical device to ensure orders are being performed and completed five times a week for eight weeks by the DON and/or designee. • On 01/27/25 Staff education on the PleurX chest tube was provided by the DON. • On 01/29/25, a whole house skin check was conducted on all residents to identify anyone that had medical device orders in place for the care of the medical devices per the DON. There were no other residents identified. This deficiency represents non-compliance investigated under Complaint Number OH00161852. 365933 Page 3 of 3