Health inspection·January 20, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident representative for 1 of 4 residents (Resident #1) reviewed for changes in condition. The facility failed to notify Resident # 1's family member of continued emesis and a subsequent order for Resident # 1 to be sent out to the hospital. This deficient practice could result in denial of resident rights of family to be notified with any change of status. Failure to notify family members of significant change of status could affect any resident at risk for hospitalization. Findings included: Record review of Resident # 1's admission Record dated [DATE] revealed a 53- year-old male who admitted to the facility on [DATE] and expired on [DATE]. His diagnoses included chronic obstructive pulmonary disease (causes airflow blockage and breathing problems), Type 1 Diabetes (chronic condition in which the pancreas produces little or no insulin), Type 2 Diabetes (chronic condition that affects the way the body processes blood sugar), Indeterminate colitis (chronic digestive disease), rheumatoid arthritis (immune system attacks healthy cells in body causing pain & swelling), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side, Stage 3 chronic kidney disease, heart disease, myocardial infarction (heart attack), and legal blindness. Record review of Resident # 1's Order Summary Report dated [DATE] revealed the resident had an order for DNR/Do Not Attempt Resuscitation with an order date oof [DATE]. Resident # 1 had PRN orders for both Meclizine and Ondansetron (AKA Zofran), for the treatment of nausea and vomiting. Record review of Resident # 1's Progress Note dated [DATE] at 4:50 AM written by LVN B revealed, Resident put on call light and upon entering room he stated he had thrown up. Observed a small amount of emesis that was clear-brown tinged. Resident was administered Zofran 2 hours prior to episode. Resident stated he did not want to eat dinner because he felt nauseous since lunch time. Checked blood glucose and it was 144/DL. Resident vs was 130/70, 69 (HR), 97.0 (temp), Spo2 98%. No signs of distress. Will continue to monitor. Will report to oncoming staff. Record review of Resident # 1's Progress Note dated [DATE] at 8:45 AM written by LVN A revealed, Entered resident room resident alert and oriented no episodes of nausea or vomiting noted. Blood sugar 272 at this time. Head of bed raised 90 degrees. Page 1 of 3 675081 675081 01/20/2024 Golden Acres Living and Rehabilitation Center 2525 Centerville Rd Dallas, TX 75228

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident # 1's Progress Note dated [DATE] at 11:30 AM written by LVN A revealed, Entered resident room, resident noted to have episode of vomiting. Light brown tinged emesis noted on resident alert and oriented. Resident states he vomited and doesn't feel good. PRN Ondansetron administered at this time. Will continue to monitor. Record review of Resident # 1's Progress Note dated [DATE] at 11:41 AM written by LVN A revealed, Head to toe assessment completed on resident, resident in bed, head of bed raised 90 degrees. Resident alert and oriented xs3. Aware of situation and surroundings. No shortness of breath or labored breathing noted. Abdomen soft and non-distended resident last known bowel movement was [DATE]. NP [name] was present in the facility notified of resident having episode of vomiting and condition. Order given to send resident to ER for further evaluation. Record review of Resident # 1's Progress Note dated [DATE] at 12:50 PM written by LVN A revealed, Entered resident room, resident noted to have no respirations. Unable to obtain vital signs. at this time. Resident has DNR code status order. NP [name] Called and notified of resident findings. Record review of Resident # 1's Progress Note dated [DATE] at 2:02 PM written by RN C revealed, Resident lying supine in bed,pupils fixed and dilated,no chest movement noted,no pulse and no B/P,PRONOUNCED AT 13:45 PM. The progress notes did not indicate that Resident # 1's family was notified of the continued emesis that prompted the NP to order for him to be transferred to the hospital for further evaluation. An interview with Resident # 1's family member on [DATE] at 6:24 PM revealed the facility did not notify her that there was an order for Resident # 1 to be sent out to the hospital. She stated she was not contacted by the facility until 2pm on [DATE] when they called to inform her that Resident #1 had expired. An interview with LVN A on [DATE] At 11:36 AM, revealed anything about labs or patient condition changing from their baseline would constitute calling the family to notify of a change in condition. LVN A stated that if he called a family, he would document it. LVN A stated on [DATE] Resident #1 was having nausea and vomiting, his vitals were normal. LVN A stated he informed the nurse practitioner who subsequently ordered for Resident # 1 to be sent to the hospital. LVN A stated he called for non-emergency transport because Resident # 1's vital signs were normal. LVN A stated after he called for transport, he went back to assess Resident #1 and found that he did not have vital signs or respirations. LVN A stated the emesis would constitute a change of condition. LVN A stated he remembered calling the family of Resident #1 or perhaps it was the nurse (LVN B) that worked before his shift started that day that informed the family of the emesis. An interview with the DON on [DATE] at 12:06 PM revealed Resident # 1 always had emesis on an doff and that is why he had a PRN order for Zofran (a nausea medication). The DON stated one episode of emesis was not a change of condition for Resident #1; only continuous emesis with the color of ground coffee would be a change of condition. The DON stated the night nurse (LVN B) notified Resident # 1's family member that he was having emesis. The DON stated the documentation was not here, so there was an assumption that it was not done. An interview with LVN B on [DATE] at 1:02 PM, revealed she did not see Resident # 1's emesis as a change in condition. If the emesis was coffee ground in color and it was a large amount, she would see it as severe and notify the physician and the family. LVN B stated Resident # 1 only had a small 675081 Page 2 of 3 675081 01/20/2024 Golden Acres Living and Rehabilitation Center 2525 Centerville Rd Dallas, TX 75228

F 0580 Level of Harm - Minimal harm or potential for actual harm amount of emesis and it was clear mucous on her shift. LVN B stated she did not call Resident# 1's family. She stated while she was waiting to be relieved from her shift the morning of [DATE] Resident #1's family member called the facility, and she answered the phone. LVN B stated she spoke with the family member briefly, informed her about the small emesis and that Zofran was given, and told the family member that LVN A would call her back. Residents Affected - Few An interview with ADM on [DATE] at 1:51 PM revealed LVN A should be notifying and documenting in the notes. The ADM stated the facility talked to Resident # 1's family member, but it was not documented so the DON went back to document on [DATE]. The ADM stated there should have been a follow up call to the family when the NP said to send Resident #1 out. The ADM stated it was their procedure for the nurse to document and they had started in-servicing staff on documentation. An interview with the NP on [DATE] at 9:38 AM revealed the nurse had informed her that Resident #1 had emesis but did not have shortness of breath, nor was in distress. When the emesis happened the second time in a short while, the NP stated she told the nurse to send him out for an ER evaluation because of his history of hospitalization due to colitis a few years ago. The NP stated depending on the condition, if the resident was alert, not in distress, and had no shortness of breath, the resident would be considered stable so non-emergency transport would be reasonable. She stated only if there were signs of distress would a 911 call be needed. Record Review of facility's policy titled, Change of Condition Reporting, dated 5/2007, revealed, Acute Medical Change .3. The responsible party, POA, or guardian will be notified that there has been a change in the resident's condition and what steps are being taken .Routine Medical Change 7. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. 675081 Page 3 of 3