Health inspection·September 18, 2023

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's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition. The facility failed to ensure Resident #1's POA was notified that he had a fall and was sent out to the local hospital for further evaluation. This failure placed residents at risk of a decreased quality of life and increased psychosocial harm by depriving residents of the right to have representative(s) notified of significant changes in resident condition. Findings included: Record review of Resident #1's undated face sheet printed 09/16/23 reflected a 90 -year-old male who was admitted to the facility on [DATE] with diagnoses including dementia(loss of memory), hypothyroidism(thyroid gland doesn't produce enough thyroid hormone), lymphedema(blockage in the lymphatic system), congestive heart failure(heart does not pump blood as well )((hypertension(high blood pressure) Record review of Resident's #1's undated face sheet printed 09/16/23 reflected the POA was Resident #1's emergency contact, representative family member contact, financial responsible, and authorized representative. Record review of Resident #1's undated care plan reflected that Resident #1 had a fall on 9/15/23 in his room. Resident #1 hit his head and was sent out to Emergency Room. Goal-short term goal target date 10/15/23 for injury to heal without complications. Record review of Resident #1's MDS dated [DATE] revealed in Section G Functional Status that he was marked as limited assistance of locomotion on the unit. Section C was blank for his BIMS score. In an interview on 09/16//23 at 12:45 PM the POA stated that the facility did not notify her that Resident #1 had a fall and was sent out to the local hospital for further evaluation. The POA stated unnamed hospital staff contacted her on 09/15/23 around lunchtime (exact time unknown) to let her know that Resident # 1 was in the emergency room being treated. The POA stated she then contacted the nursing facility after speaking with unnamed hospital staff and spoke with LVN A and was told Resident # 1 had a fall and was sent out for further evaluation. The POA stated she was told by LVN A that Page 1 of 3 675096 675096 09/18/2023 Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645

F 0580 Level of Harm - Minimal harm or potential for actual harm Resident #1 had taken a fall in his room around breakfast (exact time unknown). The POA stated that Resident #1 had a history of falls due to dementia. The POA stated Resident #1 used his walker independently and did not rely upon facility staff for walking assistance The POA stated her only concern was the nursing facility not contacting her immediately to let her know Resident #1 had taken a fall and was sent out to the hospital for further evaluation. Residents Affected - Few Record review of Resident #1's progress notes revealed LVN A created a late entry progress note on 09/15/23 at 2:02 PM with an effective date of 09/15/23 at 9:15 AM which stated this nurse entered room resident lying on floor by bed on back. Bleeding noted to small abrasion to back of head. Resident complained of pain all over. Resident repeating several times Please help me Instructed staff to call 911. Head-to-toe assessment abrasions to BUE noted. This nurse at resident's side when EMS arrived. Left facility via stretcher per ambulance to local hospital for evaluation. Administrator, In house staff aware, and contacted family nurse practitioner. In an interview on 09/18/23 at 11:00 AM the Administrator she stated that on 09/15/23 time not recalled LVN A advised her that she did not contact the POA when Resident #1 had a fall and was sent out to the hospital for evaluation The Administrator stated the POA was notified by the local hospital that Resident #1 was being evaluated and that is when the POA called the facility and spoke with LVN A on what had occurred. The Administrator stated LVN A stated that she knew to call the POA but was so busy with other nursing duties that it had slipped her mind. The Administrator stated it was LVN A responsibility to call the POA to notify her of Resident # 1 being sent out to the hospital for further evaluation due to a fall. The administrator stated facility staff are trained to call the POA when Residents are sent out to local hospital for further treatment. In an interview on 09/18/23 at 2:21 PM LVN A stated she was responsible for contacting the POA on 09/15/23 when Resident #1 took a fall and was sent out to the local hospital. LVN A stated she knew to contact the POA immediately after the incident and it was her responsibility to notify the POA. LVN A stated after Resident # 1 was sent to the local hospital for further evaluation; she was attending to other nursing duties that caused her not to contact the POA. The LVN A stated the POA had contacted her once she had received notification from the local hospital to find out what had happened. LVN A stated she was happy that the local hospital notified the POA that Resident # 1 was there being treated. LVN A stated she had been in nursing for several years and she had never missed calling families when incidents occur. LVN A expressed how important it is to notify families in the event incidents occur. Review of the facility's steps in the procedure after a fall revised on October 2010, revealed: The purpose of this procedure is to provide guidelines and steps in the procedure. Procedure: Nursing staff will notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the practitioner immediately by phone. Reporting: Notify the following individuals when a resident falls: A. The resident's family 675096 Page 2 of 3 675096 09/18/2023 Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645

F 0580 B. Level of Harm - Minimal harm or potential for actual harm The attending physician (timing of notification may vary, depending on whether injury was involved) C. Residents Affected - Few The Director Of Nursing Services D. The Nursing Supervisor on duty 675096 Page 3 of 3