Health inspection·July 31, 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. Based on record review, interviews, and facility policy review the facility failed to ensure accurate documentation in the medical record for respiratory care and enteral tube feeding care for Resident #93. This affected one resident (#93) of three residents reviewed for respiratory care and enteral tube feeding care. The facility census was 92. Findings include: Review of the medical record for Resident #93 revealed an admission date of 04/07/23 with diagnoses including traumatic subdural hemorrhage, acute and chronic respiratory failure, gastrostomy, tracheostomy, and personal history of traumatic brain injury. Review of Resident #93's physician's orders revealed he had orders for staff to check the residuals of his tube feeding every shift dated 05/28/23 and discontinued 06/05/23; to administer well water only, no tap water every shift dated 05/28/23 and discontinued 06/05/23; perform tracheostomy care twice daily and as needed every day and evening shift dated 05/28/23 and discontinued 06/05/23; change the tracheostomy inner cannula daily and as needed dated 05/28/23 and discontinued 06/05/23; and to monitor his oxygen level every four hours and if any signs of distress or oxygen is less than 90 percent (%), staff were to uncap him and apply humification dated 07/05/23. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) reviewed for June 2023 and July 2023 revealed nursing staff did not document these items as being completed: Tube feeding residuals on dayshifts on 06/01/23, 06/03/23 and 06/04/23 and on evening shift on 06/02/23. Well water only, no tap water on dayshifts on 06/01/23, 06/03/23 and 06/04/23 and on evening shift on 06/02/23. Tracheostomy care on dayshifts on 06/01/23 and 06/04/23 and on evening shift on 06/02/23. Change tracheostomy inner cannula on 06/01/23 and 06/04/23. Oxygen saturation on 07/07/23 at 8:00 A.M., 12:00 P.M. and 4:00 P.M.; on 07/09/23 at 8:00 A.M. and 12:00 P.M.; on 07/11/23 at 8:00 A.M. and 12:00 P.M., and on 07/12/23 at 8:00 A.M. and 12:00 P.M. Interview on 07/27/23 at 3:49 P.M. with the Director of Nursing (DON) revealed there were times the Page 1 of 2 366343 366343 07/31/2023 North Royalton Post Acute 9055 West Sprague Road Parma, OH 44133

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff did not sign off on the MAR and TAR. She stated she had been educating to ensure they were documenting when they completed a task. Interview on 07/31/23 at 8:35 A.M. with the Administrator verified staff had completed the missing documentation on the MARs and TARs for Resident #93 on 07/29/23. She provided hand signed copies of Resident #93's MARs and TARs for the months of June 2023 and July 2023. She stated the staff had completed the tasks, just failed to document in the medical record. Review of the facility policy titled Oxygen Administration, dated 06/08/22, revealed the staff were to document in the medical record after assessing the resident. Review of the facility policy titled Enteral Tube Feeding-Bolus and Continuous, dated 06/08/22, revealed the staff were to document after checking residuals and feedings. 366343 Page 2 of 2