Health inspection·January 16, 2025

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure parental fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #1) reviewed for parental fluids. Residents Affected - Few The facility failed to ensure Resident #1's right arm PICC line (a thin, flexible tube that is inserted into a vein and threaded into a larger vein near the heart for long-term intravenous treatments) dressing was changed weekly (the dressing was dated 01/06/2025 upon observation on 01/16/2025) as ordered by her physician. This failure placed residents with intravenous (within the vein) lines at risk of developing infection. Findings included: Record review of Resident #1's face sheet dated 01/16/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with sepsis (a life-threatening complication of an infection), urinary tract infection (an infection in any part of the urinary tract), dysphagia (difficulty swallowing), and mild cognitive impairment (a brain condition that causes subtle changes in thinking and memory). Record review of Resident #1's admission MDS dated [DATE] revealed she had a BIMS score of 0 (severe cognitive impairment) and she did not exhibit behaviors or reject care. Record review of Resident #1's care plan, revised on 01/10/2025 revealed the following care areas: * Resident #1 has intravenous PICC line. Goal included: The resident will not have any complications related to IV therapy. Interventions included: Administer IV medications as ordered. Check dressing at site daily. Monitor for signs and symptoms of infection. Flush the ports/lines as ordered. Monitor location of implanted port for signs and symptoms of infection: redness, tender, swelling, and drainage. Report to the physician if noted. Monitor/document/report to physician PRN s/sx of infiltration at the site (when fluid from the IV leaks into the surrounding tissue). * Page 1 of 3 455725 455725 01/16/2025 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0694 Level of Harm - Minimal harm or potential for actual harm Resident #1 was on antibiotic therapy related to infection (sepsis). Goal included: Resident #1 will be free of any discomfort or adverse side effects of antibiotic therapy. Interventions included: Administer medication as ordered. Record review of Resident #1's physician's orders for January 2025 revealed the following: Residents Affected - Few * Change Right Arm PICC Line Dress (dressing) Q Weekly on Mondays in the morning every Monday. Order Date: 12/30/2024. Start date: 12/30/2024. Record review of Resident #1's TAR for January 2025 revealed the following: * Change Right Arm PICC Line Dress (dressing) Q Weekly on Mondays in the morning every Monday. Further review of Resident #1's TAR revealed the entry block for Monday, 01/13/2025 was checked (indicating the treatment was completed) and initialed by LVN A. Observation and interview with Resident #1 on 01/16/2025 at 12:30 p.m. revealed she was asleep in her bed with her eyes closed. Resident #1's RP was present and stated the dressing on Resident #1's PICC line should be changed every seven days, which meant it should have been changed by then. Observation of Resident #1's right arm revealed the dressing on her PICC line was dated, 01/06/2025. Resident #1 woke up and said hello at her RP's request, but she did not answer questions. In a telephone interview with Resident #1's NP on 01/16/2025 at 1:12 p.m., he stated he was not sure of what Resident #1's dressing change order was, but typically, the dressing on a PICC line should be changed once per week. He said the dressing was impregnated (soaked or saturated with a substance) with chlorohexidine (an antiseptic which kills bacteria), which fights the risk of infection. He stated changing the dressing weekly was important because it fought infection. He stated if the dressing was dated 01/06/2025, it should have been changed by the 13th, or the 14th at the latest. In an interview with the DON on 01/16/2025 at 1:25 p.m., she stated if 01/06/2025 was written on Resident #1's dressing, that was the last date it was changed. She said if the dressing was supposed to be changed on Monday, 01/13/2025, it was three days behind. She said LVN A worked the morning shift on 01/13/2025 and was responsible for changing the dressing. In a telephone interview with LVN A on 01/16/2025 at 1:31 p.m., she stated she normally worked the 6:00 a.m. to 6:00 p.m. shift on Resident #1's hall. She stated Resident #1 had an intravenous line because she received antibiotic therapy. She stated Resident #1 had an order to change the dressing on the line every Monday. She stated she was not sure if she changed the dressing on Monday, 01/13/2025. She stated staff wrote dates on the dressings to document the day it was put on or changed and if Resident #1's dressing was dated 01/06/2025, then that was the last date it was changed. She said she was not sure what happened or why the TAR indicated it was changed on 01/13/2025 but the dressing was dated 01/06/2025. She stated the dressing had to be changed weekly for hygiene reasons. She said when she changed the dressing, she checked the skin and cleaned the area around the line to make sure the tissue stayed healthy. She said not changing the dressing weekly could produce infection. 455725 Page 2 of 3 455725 01/16/2025 Oakmont Healthcare and Rehabilitation of Humble 8450 Will Clayton Pkwy Humble, TX 77338

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview with the DON and Regional Director of Operations on 01/16/2025 at 1:55 p.m., the DON stated staff dated residents' dressings to indicate the date it was changed. The DON said if the order said the dressing should be changed weekly, then it should be changed weekly. The Regional Director of Operations stated the dressing itself did not contain medication, but the dressing change equipment came in a kit, which included Chloraprep (a sterile, antiseptic solution used to prepare the skin that contains 2% chlorhexidine gluconate). The DON and Regional Director of Operations went to Resident #1's room and looked at the dressing on her right arm. The dressing was still dated 01/06/2025. Observation on 01/16/2025 at 2:10 p.m. revealed the DON cleaned and changed Resident #1's PICC line dressing. In an interview with Resident #1's physician on 01/16/2025 at 2:20 p.m., she stated if Resident #1's dressing change order said weekly, then staff should be changing the dressing weekly. She said it was important to clean and change the dressings on IV lines to protect against infection. He said she was not aware that orders were not being followed. She said it was important for staff to follow orders to keep the resident healthy. Record review of the facility's undated policy titled, Nursing Facility Medication Administration revealed, . 2. The facility staff administering medication shall comply with the following: a. No medication shall be given to any resident unless ordered by a physician. B. Medications shall be administered unless the resident refuses or exhibits symptoms that contraindicate medication administration. C. If a medication is not administered, the staff member shall document in the resident's record why the medication was not administered . 3. Medications shall be administered only to the resident for whom they are prescribed, given in accordance with directions on the prescription or the physician's order, and recorded on the resident's medication record . 6. The facility shall maintain an individual medication record for each resident to whom the facility administers medication in which: a. Physician orders are recorded and signed. B. All medications are recorded as given, documenting name of the medication, date and time given, and signed by the individual administering the medication. Record review of the facility's undated policy titled, Peripheral IV Dressing Change revealed, . Procedure . 12. Label new dressing with date of insertion, date of change (if not insertion date), gauge used, and initials . 455725 Page 3 of 3