Health inspection·February 2, 2024

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure medical appointments were scheduled timely and transportation was arranged for medical appointments. This affected one (Resident #45) of three residents reviewed for medical appointments. The census was 69. Residents Affected - Few Findings include: Review of Resident #45's medical record revealed Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to type two diabetes, asthma, anxiety disorder, heart failure, tachycardia, acute kidney failure, chest pain, encephalopathy, hypertension, hyperlipidemia, and cognitive communication deficit. Review of Resident #45's Minimum Data Set assessment, dated 01/11/24, revealed Resident #45 was cognitively intact. Review of Resident #45's progress note, dated 09/01/23, revealed social services scheduled a dental/oral surgery appointment for Resident #45 on 01/11/24. The progress note stated she communicated this information, but the note did not specifically state who she communicated this information to. Review of Resident #45's progress notes, dated 11/23/23 and 12/07/23, revealed Resident #45 was asked who his cardiologist was. He stated he did not have one, but he needed to have an exam/stress test prior to his oral surgery to ensure he could handle the procedure. On 12/07/23, the facility documented they would contact a cardiologist to schedule an appointment. There was no other documentation to support an appointment was made with the cardiologist and/or what the result of any communication with the cardiologist was. Review of Resident #45's physician orders, dated 09/01/24 to 01/11/24, revealed there were no physician orders related to Resident #45's oral surgery appointment which was scheduled for 01/11/24. Also, there was no documentation to support any cardiologist appointment was scheduled prior to the oral surgery which was scheduled for 01/11/24. Review of Resident #45's progress notes, dated 01/11/24, revealed the facility called the oral surgery center to confirm Resident #45 had an appointment that day, but also to reschedule the appointment for June 2024. Interview with Resident #45 on 02/02/24 at 11:30 A.M. revealed he knew his oral surgery appointment had been scheduled for 01/11/24. Resident #45 was frustrated that the facility did not schedule Page 1 of 2 365946 365946 02/02/2024 St. Theresa Care Center 7010 Rowan Hill Drive Cincinnati, OH 45227

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few transportation for him to go to that appointment. He stated the facility did not know he had an appointment that day, even though it was scheduled. He revealed he needed/wanted to go to the appointment and now he has to wait five more months to have the oral surgery completed. Interview with the Director of Nursing (DON) on 02/02/24 at 2:05 P.M. confirmed Resident #45 had an oral surgery appointment scheduled for 01/11/24, but when that day arrived, no staff were aware of the appointment; so Resident #45 did not go to the appointment. The social worker who was working with him on the appointment, no longer worked in the facility and she did not communicate well enough about the appointment so the staff could be prepared for it. Interview with Licensed Practical Nurse (LPN) #105 on 02/02/24 at 2:50 P.M. revealed the facility staff did not know about Resident #45's oral surgery appointment on 01/11/24. She confirmed there was a progress note that confirmed the appointment was made by the previous social worker, but it was never communicated to the nursing staff and put into his physician orders. She confirmed the next available appointment was not until June 2024. She also confirmed there was no documentation to support the cardiologist was contacted prior to his scheduled appointment on 01/11/24, so even if he did go to his oral surgery appointment, she was not sure if the surgery could have occurred. This deficiency represents non-compliance investigated under Complaint Number OH00150210. 365946 Page 2 of 2