Health inspection·April 27, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A provided Resident #1 adequate supervision and assistance during his personal hygiene after providing Resident #1 with two disposable razors on nightshift of 04/24/23 resulting in self-inflicted marks on 04/25/23. This failure could place residents at risk for accidents and injury. Findings included: Review of Resident #1's facility electronic face sheet, dated 04/27/23, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: paraplegia, depression, adjustment disorder with mixed anxiety, insomnia, hypotension, and constipation. Review of the MDS assessment, dated 03/07/23, revealed Resident #1 was cognitively moderately impaired with a Brief Interview for Mental Status score of 11 and required limited assistance of one staff member for ADLs, which included personal hygiene. Record review of the Care Plan, revised on 04/27/23, revealed Resident #1 had focus for ADL self-care performance deficit related to disease processes, aggressive behavior, disease process paraplegia, limited mobility, and musculoskeletal impairment. Review of the CNA's documentation in the facility's database Task tab, for the dates 04/14/23 through 04/26/23, revealed CNAs checked that Resident #1 received limited and extensive assistance as well as total dependence with personal hygiene during documented timeframe. Review of progress note by LVN B for Resident #1, dated 04/25/23, revealed at 0000 [midnight] I took resident his routine medicine. While talking with resident I noticed that there was some dried blood on his left wrist. Asked resident what happened to his wrist, and he stated Oh, I just messed it up. Asked how he messed it up and tried to take wrist to look at it and resident slapped my hands and pulled wrist away. I tried again and resident slapped my hands again and said that it is nothing. I also noticed a razor blade from a disposable razor that had been taken apart on the bedside table. I took the blade and spoke with the other nurse (LVN C). The other nurse (LVN C) on duty was able Page 1 of 5 675089 675089 04/27/2023 Focused Care at Sherman 817 W Center Sherman, TX 75090

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to persuade resident to let her look at the left wrist. Both nurses (LVN B and C) went to look at the left wrist. Noted 24 straight cuts across the wrist area .Resident was immediately placed under continuous one on one observation. ADM was notified and arrived at 0145 and EMS was notified of need of transport to ER at 0050 and arrived at 0130. EMTs spoke with resident (Resident #1) and resident was very angry and refusing to go .resident was very angry and agitated and verbally abusive. Left via stretcher .at 0248 [2:48 AM] to hospital. Review of Ambulance Company H's-Patient Care Report dated 04/25/23 for Resident #1 revealed the following: Chief complaint organ system: behavioral/psychiatric Provider's Primary Impression: suicide attempt Possible injury: Yes Primary symptom: Strange and inexplicable behavior Narrative: .dispatched and responded to Nursing Facility I for a patient that had reportedly sustained multiple lacerations. Upon arrival patient .alert and oriented x4 .patient reported to EMS that he lacerated his left wrist multiple times using a razor blade. The lacerations were superficial, all bleeding controlled prior to arrival. Facility staff reported patient had stated suicidal ideations, despite denying these claims to EMS crew. Review of ED physician record for Resident #1, dated 04/25/23, reflected history of present illness: The patient presents with psychiatric problem. The onset was just prior to arrival and chronic. The course/duration of symptoms is constant. The degree of symptoms is moderate. Self-injury: none. The exacerbating factor is none. The relieving factor is none. Risk factors consist of none .Additional history [AGE] year-old male presents via police from nursing facility for reported suicide attempt. Patient is present with multiple abrasions to left wrist. Patient denies suicide attempt and states that nursing facility is lying. Physical Examination Skin: warm, dry, pink, multiple superficial abrasions of left wrist. Neurological: alert and oriented to person, place, time, and situation .normal speech observed. Psychiatric: Cooperative, appropriate mood & affect. Medical Decision Making: documents reviewed .suicide risk screening. Review of Provider J's Assessment for Least Restrictive Environment/Crisis Plan dated 04/25/23 for Resident #1 revealed: II. Hospitalization does NOT appear to be the least restrictive environment for this individual for the following reason: This person denies being actively suicidal/homicidal & has no plan/intent for harm to self or others. IV. Individual/support system input/preferences regarding plan: The plan is for Resident #1 to return to nursing home upon medical clearance. Review of progress note by LVN B for Resident #1, dated 04/26/23, revealed at 12:36 AM Resident #1 returned from hospital .Resident is in a pleasant mood .at 2345 [11:45 PM] nurse from hospital stated in report that resident stated that he has no intentions of harming himself .cleared him to come 675089 Page 2 of 5 675089 04/27/2023 Focused Care at Sherman 817 W Center Sherman, TX 75090

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back to the facility when he has been medically cleared. Nurse giving report stated that he has been medically cleared and is on his way back to the facility with no new orders. Review of progress note by ADON for Resident #1, dated 04/26/23 revealed upon focused care rounds this morning, this nurse discussed recent events with the resident. Resident states It was nothing I was just messing around.This nurse asked this resident if he had any intentions of ending his life. Resident stated no, if I wanted to harm myself, I would have done it You all made this big fiasco, and it was nothing . Review of Resident #1's current electronic physician orders for April 2023 revealed no treatment orders for left wrist. On 04/13/23 order written please refer to senior psych care and/or senior psychological care for evaluation and treatment (Dx: increased agitation, anxiety, depression). Review of Resident #1's electronic medication record for April 2023 revealed: antidepressant monitoring every shift for side effects: 19) suicide ideations. Record indicated positive for suicidal ideations one time since admission, on the night of 04/25/23 which was the date of the left wrist incident. Interview on 04/27/23 at 10:05 AM with Resident #1 while in bed. Resident #1 revealed when Resident #1 was asked about the incident that occurred Monday night Resident #1 immediately stated he was not trying to harm himself. Resident #1 stated he would never hurt himself. Resident #1 stated he asked a CNA, name unknown, for two razors to shave himself. Resident #1 stated he was just playing with the razor blades. Resident #1 stated the marks on his left wrist were just scratches. Resident #1 stated when the incident occurred his wrist bled a tad, it was not dripping with blood and did not cause him pain. Resident #1 stated while at the hospital they did not perform a treatment to his left wrist. Resident #1 stated he never said he wanted to kill himself. Resident #1 stated his left wrist had not been in pain. Observation on 04/27/23 at 10:06 AM of Resident #1's underside of left wrist revealed approximately 10 scratch like markings that were approximately 1.5 to 2.0 inches in length, the left wrist was without a bandage, clean, no redness, no bruising and had the appearance of scab like scratches/superficial abrasions. Interview on 04/27/23 at 12:16 PM with CNA A via telephone revealed Resident #1 put on his call light sometime before midnight and asked for a razor. CNA A stated she provided Resident #1 with two disposable razors and left the room. CNA A stated that LVN B came to me and showed me a razor blade inside of a cup, LVN B stated that Resident #1 had cut his wrist. CNA A stated she went to look at Resident #1's wrist and did witness the cuts to his left wrist, CNA A stated she then left Resident #1's room and did not return. CNA A stated she did not know that Resident #1 needed assistance with personal hygiene since it was not routine for the nightshift to assist with personal hygiene such as shaving. CNA A stated she can locate information about a resident's ADLs in the CNA kiosk, but she did not look for Resident #1's personal hygiene assistance needs in the kiosk. CNA A stated she could have asked Resident #1's nurse about Resident #1's personal hygiene assistance but CNA A stated she did not. CNA A stated she should have asked the nurse prior to providing Resident #1 the razors and leaving him unsupervised. CNA A stated it was a mistake to provide the razors to Resident #1 and leave him unattended, CNA A stated Resident #1 did lot for himself without assistance. CNA A stated Resident #1 was alert, oriented and never had mentioned anything about suicide or harming himself. Interview on 04/27/23 at 8:40 AM with the ADM and DON revealed the ADM stated the night of the 675089 Page 3 of 5 675089 04/27/2023 Focused Care at Sherman 817 W Center Sherman, TX 75090

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incident Resident #1 had stated to the ADM that he had messed up his wrist a little bit, but he was not trying to kill himself. The ADM and DON stated that Resident #1 was a newly admitted resident from Nursing Facility D. The DON stated that Resident #1 tried to be as independent as he can. The DON stated that Resident #1 shaves himself and that was why he had razors. The DON stated that her expectation was when a resident asked for a razor that the staff member can provide the razor to resident and was to remain with the resident until the resident is finished using the razor, amd then dispose of the razor in the sharp's container. The ADM and the DON both stated that residents were to be supervised when provided a razor. The ADM and the DON both stated that they were not aware of Resident #1 having a history of suicidal thoughts/attempts or thoughts/attempts at harming himself. The DON stated Resident #1 returned from hospital without treatment to his left wrist. The DON stated that the facility had two independent residents for shaving and those residents had an electric razor. The DON stated Resident #1 was referred to psychological care services for requested couseling services related to depression not suicidal thoughts in April. Interview on 04/27/23 at 9:25 AM with LVN B via telephone revealed LVN B went to Resident #1's room around midnight Monday night, 04/24/23 to give Resident #1 his routine pain medication. LVN B stated that she observed dried blood on Resident's #1 left wrist and when LVN B attempted to look at the wrist Resident #1 pulled back and Resident #1 stated he was just messing around. LVN B stated she saw approximately 24 marks to Resident #1's left wrist. LVN B stated there was a blade from a disposable razor on Resident's #1 bedside table. LVN B stated she cleaned the dried blood from Resident's #1 wrist and wrapped gauze around it, Resident #1 immediately removed the gauze. LVN B stated the left wrist had no broken skin and was not bleeding that the wrist had dried blood on it. LVN B stated Resident #1 did not express any pain to his left wrist. LVN B stated when she asked Resident #1 why he cut his wrist, Resident #1 stated I wanted to see what it felt like, I was just messing around. LVN B stated that Resident #1 had not expressed or had any indication of suicidal thoughts. LVN B stated that CNA A had given Resident #1 the razors because he asked CNA A for a razor so Resident #1 could shave. LVN B stated that if you provide a resident with a razor, you are to either assist the resident with the razor or supervise the resident with the razor, you are never to leave a resident unattended with a razor. LVN B stated the risk of leaving a resident unattended with a razor could result in injury. Interview on 04/27/23 at 10:31 AM with the SW revealed Resident #1 has not expressed any suicidal thoughts nor did Resident #1 have a history of suicide. The SW stated that Resident #1 was alert and oriented and able to make his needs known. The SW stated that the resident was referred to psychological care services due to his current life situation after his accident, he had requested couseling services for depression not suicidal thoughts therefore an order for psychological care services was written in April. The SW stated that she spoke with Resident #1 after the incident and Resident #1 stated that he was playing around he was not trying to cause harm nor wanted to cause harm, he said it was not a big deal, he wasn't trying to do anything. Interview on 04/27/23 at 10:43 AM with the ADON revealed Resident #1 is alert and oriented. Resident #1 can shave himself but does better with assistance. Resident #1 has had no thoughts of suicide, no reports of suicidal ideations. ADON stated her expectation is for staff not to give a resident a razor and leave them unattended/unsupervised, a resident must be supervised if they are given a razor. The ADON stated that the risk of leaving a resident unsupervised with a razor could result in injury or harm to resident or other residents. Interview on 04/27/23 at 11:07 AM via telephone with the ADM E and the SW F from Nursing Facility D revealed Resident #1 had no history or suicidal thoughts/ideations or attempts during his 675089 Page 4 of 5 675089 04/27/2023 Focused Care at Sherman 817 W Center Sherman, TX 75090

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission. The ADM E and the SW F both stated that Resident #1 was alert, oriented and able to make needs known. Interview on 04/27/23 at 12:27 PM via telephone with LVN C revealed LVN B came to her on the evening on 04/25/23 to observe Resident #1's left wrist. LVN C stated that Resident #1 stated he had used razor blade to make the marks on his left wrist. LVN C stated Resident #1 was alert, oriented and never talked about suicide in the past. LVN C stated Resident #1's left wrist was not bleeding, LVN B cleaned Resident #1's wrist and wrapped it with gauze however Resident #1 immediately removed the gauze. LVN C stated the red marks to Resident #1's left wrist were superficial. LVN C stated a resident is to be supervised with razors and never left unattended. LVN C stated the risk of leaving a resident unattended with a razor could result in injury. Review of facility in service training dated 04/27/23 revealed Topic/Title: Shaving. Contents or summary of training .if a resident asks to be shave themselves, they must be supervised during the time they are shaving, and the razor must be taken out of the room and put in sharps container when they are finished. Review of facility's only policy for ADLs related to personal hygiene including shaving provided by the ADM revealed a policy titled Quality of Life-Resident Self Determination and Participation, revised December 2016, policy statement Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. 1. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments, and plans for care, including: b. Personal care needs, such as bathing methods, grooming styles and dress . 675089 Page 5 of 5