Health inspection·November 4, 2023

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the resident's needs safely and in a manner that promotes each resident rights, physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for nursing practices. The facility failed to ensure LVN A had the competency to retrieve a physician order before performing an invasive examination. The noncompliance was identified as PNC. The noncompliance began 10/18/23 and ended on 10/27/23. The facility had corrected the noncompliance before the investigation began. This failure could place the residents at risk of physical and psychosocial harm. Findings included: Record review of Resident #1's health record revealed a [AGE] year-old female, admission date 08/09/2022, Diagnoses: other intestinal obstruction unspecified as to partial versus complete obstruction (digested material is prevented from passing normally through the bowel), acute and chronic respiratory failure with hypercapnia (respiratory failure due to mechanical defects, central nervous system depression, imbalance of energy demands of central controllers), pleural effusion (fluid buildup between the lung and the chest), not elsewhere classified, unspecified diastolic heart failure (heart's main pumping chamber becomes stiff and unable to fill properly), hypertension (high blood pressure), fatty liver, unspecified cirrhosis of liver (chronic liver damage), hypokalemia (low potassium), edema (swelling caused by too much fluid trapped in body tissue), portal vein thrombosis (narrowing or blockage of the portal vein by a blood clot), unspecified abdominal pain, abdominal distension (bloating and swelling in belly area), muscular dystrophy (genetic diseases that cause progressive muscle weakness and loss of muscle mass), unspecified, Bells' palsy (muscle weakness on one side of face), dysphagia (difficulty swallowing), oropharyngeal phase (difficulty swallowing in mouth or throat), major depressive disorder (persistently low or depressed mood), recurrent, mild, aphonia, UTI (Urinary Tract Infection), anxiety disorder, GERD (Gastroesophageal reflux disease), pain, unspecified, constipation, other megacolon (abnormal dilation of colon), overactive bladder, difficulty in walking, lack of coordination, abnormal posture, muscle weakness, nausea with vomiting, stiffness to right shoulder, pain in right shoulder, and seasonal allergic rhinitis. Record review of Resident #1's health record revealed the most recent Care Plan dated 10/25/2023, page 15 of 35, stated Nutritional Status- [Resident #1] has a history of [NAME] and is at risk for Page 1 of 3 455901 455901 11/04/2023 Swan Health at Wichita Falls 1101 Grace St Wichita Falls, TX 76301

F 0726 Level of Harm - Minimal harm or potential for actual harm increased abdominal distress, weight loss, and GI Bleed. APPROACH: Give medications per order-monitor for effectiveness report to MD if [Resident #1] c/o increased abdominal distress. Page 30 of 35 stated, Urinary Incontinence - [Resident #1] will remain clean, dry and odor free and on occurrence of skin breakdown will occur over next 90 days. Monitor for S/S of infection and report to MD. Monitor for S/S of skin breakdown -report to MD and family. Residents Affected - Few Record review of Resident #1's physician orders, dated 10/18/23, revealed no order for a vaginal exam. Interview on 11/04/23 at 10:18 am with Resident #1 and RSD RP revealed, resident was in pain, wanted staff to fix it, and agreed to vaginal exam . No complications from the exam. RSD and RSD RP had no concerns with the exam conducted and did not know if there was an order. Interview on 11/04/23 at 12:13 pm with House Supervisor at Hospital, revealed they were informed that a nurse from the facility had done a vaginal exam, but they did not know why she did it. Initial complaint concerned that exam completed with no physician order. Interview on 11/04/23 at 3:07 pm with LVN C revealed, she would not do a vaginal exam because we don't do that here. The doctor doesn't order us to do things like that. LVN C stated that the facility would need an order to perform a vaginal exam . Interview on 11/04/23 at 4:28 pm with ADON revealed that the facility would need an order before doing an exam like that (vaginal exam) but would usually just send the resident out. ADON revealed it was LVN A that completed the exam. ADON stated, it is nursing 101 that you don't do any treatment or exam or administer medications without an order . Interview on 11/04/23 at 5:28 pm with the DON revealed that Resident #1 was having pain and was incontinent. Upon the aide wiping the resident during perineal care, aide noticed what she thought was bowel coming from the resident's vagina and went and got the nurse. LVN A asked the resident if she could do the exam and the resident agreed. LVN A completed the vaginal exam with two aides and two nurses in the room. LVN A notified the NP and he said to send the RSD out to the ER, so they did. The order to send her out to ER was dated 10/18/23 and no order for the exam. DON stated she suspended LVN A on 10/19/23 and LVN A came back on 10/27/23 and was re-educated about expectations of orders on 10/27/23. The DON stated that she reported LVN A to the Board of Nursing. The BON provided an assessment tool (Scope of Practice) for LVN A to use to prevent further incidents. The DON stated that staff knew not to complete an exam like that because we do not do them at this facility. LVN A used to work in an OBGYN clinic and had the knowledge to perform the exam, but the facility staff know not to do an exam without an order. She had been trained on Resident Rights but not specifically physician orders because that is something you learn in school. The DON stated it is common knowledge not to do anything like that (vaginal exam) without a physician's order . Record review of the Medication and Treatment Orders, Dental Services Policy dated February 2014 revealed 2. Medication orders and treatment will be administered by nursing service personnel as soon as the order has been received. Record review of the Texas Board of Nursing -Nursing Practice, page 6 of 17 revealed, The LVN in Texas provides nursing care to patients with healthcare needs that are predictable in nature, under the direction and supervision of an appropriately licensed supervisor. The term predictable describes health conditions that behave or occur in an expected way. 455901 Page 2 of 3 455901 11/04/2023 Swan Health at Wichita Falls 1101 Grace St Wichita Falls, TX 76301

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Texas Board of Nursing -Nursing Practice, page 28 of 37 revealed, The Board's position, therefore, is that LVNs are educationally prepared to administer medications and treatments as ordered by a physician, podiatrist, dentist, or any other practitioner legally authorized to prescribe the ordered medication. LVNs may also administer medications and treatments ordered by Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs) as established under Position Statements 15.1 and 15.18, relating to nurses accepting orders from PAs and APRNs, respectively. Record review of Scope of Practice revealed, 2. Is the activity or intervention authorized by a valid order? No -STOP. The facility took the following actions to correct the noncompliance: Record review of Expectations of Orders dated 10/27/23, revealed LVN A educated on having a physician order before performing any treatment. Interview on 11/04/23 at 5:28 pm with DON revealed she suspended LVN A on 10/19/23 and LVN A came back on 10/27/23 and was re-educated about expectations of orders on 10/27/23 and was reported to the Board of Nursing. BON provided an assessment tool (Scope of Practice) for LVN A to use to prevent further incident. Interview on 11/4/23 at 2:15pm with LVN B revealed she had the knowledge to not do an exam before contacting the doctor to get an order. Interview on 11/4/23 at 3:07pm with LVN C revealed she had the knowledge not to complete an exam without doctor's orders. Interview on 11/4/23 at 4:28pm with ADON revealed she knew and felt it was common knowledge for nurse's to know not to do any treatment or exam without an order. Interview on 11/4/23at 10:18 am with Family Member #5 (RSD #1 RP) revealed she believed the facility follows orders and whatever the facility staff did helped Resident #1 feel better. Interview on 11/4/23 at 12:42 pm with Familiy Member #6 (Resident #4's sister) revealed she felt staff do their job at the facility (follow orders) and make her aware of what is going on with her sister. Interview on 11/4/23 at 10:18am with Resident #1 revealed she had no worries about whatever they (facility staff) did and they (facility staff) made her feel better. Interveiw on 11/4/23 at 10:55am with Resident #2 revealed staff do what they are supposed to and she had no other concerns. Interview on 11/4/23 at 12:42 pm with Resident #4 revealed the facility staff do a thorough job and follow orders. 455901 Page 3 of 3