Health inspection·October 9, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 1 out of 3 residents (resident #1) reviewed for care plans. The facility failed to ensure care plans used by the hospice agency contained two person Hoyer lift transfer instructions. The hospice agency staff transferred Resident #1 using one person and no Hoyer lift, and because of that Resident #1 was injured. This failure could place residents at risk for their medical, physical, and psychosocial needs not being met. The findings were: Record review of a facility investigation report reflected Resident #1 was observed with a bruise to her left outer breast area on 8/28/2023. Nursing notes written on 8/28/2023 indicated a hospice CNA notified facility staff. Resident #1 was again found with a bruise on 9/4/2023, and the hospice CNA notified facility staff. Resident #1 was a 96 y/o female with diagnosis which included arthritis, osteoporosis, abnormalities of gait and mobility, lack of coordination, major depressive disorder, dementia, unspecified psychosis, and anxiety. Resident #1 has a BIMS score of 00 which indicated severe cognitive impairment. During an interview on 10/5/2023 at 4:45 PM with the DON, she said the hospice staff learned about the resident when they came in to provide care. During an interview on 10/6/2023 at 8:15 AM with the DON she said hospice staff evaluated the residents, looked at the resident's chart, and created their own care plan. The DON said the hospice chart did not have a care plan for Resident #1, but it should have one that was developed by the hospice agency. The DON said the hospice chart was separate from the facility chart. The DON said she was responsible for the staff who take care of Resident #1 which included hospice staff. During an interview on 10/6/2023 at 10:00 AM with the ADON, he revealed he did not train hospice CNAs. The ADON said Resident #1 was a two person lift for at least 4 years and it was in the resident's care plan. The ADON said he conducted the investigation of the bruises on Resident #1 and the facility CNAs knew Resident #1 was a two-person lift. The ADON said the hospice CNA was not aware Resident #1 was a two-person lift. Page 1 of 3 455687 455687 10/09/2023 Alameda Oaks Nursing Center 1101 S Alameda Corpus Christi, TX 78404

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 10/6/2023 at 11:00 AM with the DON she said the facility needed to educate hospice CNAs on proper care for the residents. The DON said the facility notified the hospice nurse after discovery of the second bruise on 9/4/2023. The DON said the hospice nurse should have known the resident was a two person lift before giving care. The DON said there was supposed to be a hospice care plan in the hospice chart and there was not. The DON said if there was not a care plan in the hospice chart, the hospice CNA would not know what the resident needed. During an interview on 10/6/2023 at 1:00 PM, the DON said the hospice service should teach their CNAs their competencies. The DON said the facility nurses and CNAs discussed resident care with the hospice nurse, but there is no record of it. The DON said the bruises inflicted on Resident #1 were not her fault, the hospice nurse should have trained the hospice CNA in resident transfers. The DON said she was responsible for the staff that take care of Resident #1, including hospice staff earlier in the day. During an interview on 10/6/2023 at 1:35 PM with the hospice CNA, she said she got her care plan from the hospice company. She said the resident care plan was downloaded to her tablet and no one reviewed it with her. She said she only used the hospice chart at the facility to sign in and out. The hospice CNA said Resident #1's care plan did not indicate she was a two-person lift, and the facility did not tell her. The hospice CNA did not know who made the care plan she used. The hospice CNA said the facility just told her where the resident was. During an interview on 10/6/2023 at 2:00 PM with the hospice nurse, she said she had been seeing Resident #1 for more than a year and received an order on 9/6/2023 to increase Resident #1's transfer to 2 people. The hospice nurse said the hospice care plan was developed by the hospice interdisciplinary team, which included the nurse case manager, social worker, medical director, and possibly a chaplain. The hospice nurse said the resident was discussed every two weeks by the IDT. The hospice nurse said she did not know who wrote the initial hospice care plan, but the hospice care started on 3/1/2021. The hospice nurse did not know Resident #1 was a two person lift for more than 4 years. During an interview on 10/6/2023 at 2:20 PM with the hospice patient care manager, she said the nurse who made the original care plan for Resident #1 was no longer with the company. She said the hospice nurse who saw the resident developed the care plan and the hospice patient care manager approved it. The hospice patient care manager said she started with the facility 18 months ago. She said the hospice care plan was not developed with the facility care plan. The hospice patient care manager said it was very difficult to coordinate with the facility. Record review of facility nursing notes reflected Resident #1 was discovered with a bruise to her left upper arm on 9/4/2023. Nursing notes written on 9/4/2023 indicate a hospice CNA notified facility staff. During a record review of facility in-services, dated 8/28/2023, it was revealed facility staff were trained on abuse and neglect, resident rights, proper transferring of residents and that all mechanical lifts are two person lifts after Resident #1 was found with a bruise. Hospice staff were not in-serviced on proper transfers at that time. Hospice staff transferred the resident without proper procedures and Resident #1 was bruised again on 9/4/2023. Record review of the facility's Hospice policy, dated 11/23/2023, reflected the following: Hospice care means a comprehensive set of services identified and coordinated by an 455687 Page 2 of 3 455687 10/09/2023 Alameda Oaks Nursing Center 1101 S Alameda Corpus Christi, TX 78404

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interdisciplinary group to provide for the physical needs of a terminally ill resident as delineated in a specific resident plan of care. The facility must designate a member of the interdisciplinary team to ensure hospice representatives are oriented to the facility and that the resident receives quality care in collaboration with the facility staff and the hospice staff. Record review of the facility's care plan policy, dated 12/5/2022, reflected the following: The baseline care plan must include the minimum health care information necessary to properly care for each resident immediately upon admission and a summary must be presented to the resident or their representative that includes initial goals of the resident, and treatments to be administered by the facility, and any updates. 455687 Page 3 of 3