Health inspection·May 22, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 8 residents (Resident #66) reviewed for advanced directives in that: 1. Resident #66 did not have his code status documented in the electronic record. This deficient practice could all residents as they may change their code status while being a resident at this facility. Findings: Review of Resident #66's face sheet dated [DATE] revealed he was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), Acute on chronic diastolic (congestive) heart failure, and Asymptomatic Human Immunodeficiency Virus (HIV) Infection. Resident is [AGE] years old. Record review of Resident #66's Electronic Medical Record (EMR) Point Click Care (PCC) revealed the Code Status was blank. Review of Resident #66's care plan revealed full code status. Interview on [DATE] at 11:45am with DON revealed the following. When asked how they would find the code status of a resident, DON stated they check the medical record tab at the top of the resident's EMR in PCC. Also, can check the code status book. If there's nothing there, he would be considered a full code. Stated the nurse or social worker places the code status into the chart during admission. DON logged on to PCC to look up Resident #66 code status. Stated it was not listed on his chart. Stated he was recently readmitted to this building from the hospital. Stated code status is for staff to know how to deal with residents appropriately in the event they stop breathing. DON informs SW that Resident #66 was missing a code status in PCC. Interview on [DATE] at 11:55am with SW revealed the following. When asked who puts the code status into the resident's chart, SW stated usually herself unless the resident comes in on the weekend, then the nurse who admits the resident will place it into the chart. Stated code status is used so the nurses will know what to do in the event of a code. They also have a code status book at the Page 1 of 2 675127 675127 05/22/2025 Focused Care at Humble 93 Isaacks Rd Humble, TX 77338

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nurse's station. Stated Resident #66 was just in the hospital and came back. His face sheet was already in the book. Stated she forgot to redo it in his chart. Stated she does audits on code status of current residents every Monday. After looking at the printout she would replace anyone who is missing a code status. SW said she was not sure how Resident #66 was missed. Interview on [DATE] at 4:55pm with Admin revealed the following. When asked how staff find a resident's code status, Admin stated they check the binder/code status book, which are kept on the crash cart near the nurse's station. The code status are checked by the nurses nightly. Code status should be entered upon admission and readmission. Code status are expected to be updated on readmission. Stated Resident #66 was readmitted from the VA. He left on hospice services and came back skilled. Admin not sure when resident readmitted but was within the last 30 days, sometime in May. Stated in the event it's not listed in PCC, staff should check in the binder on the crash cart. Walked over to the crash cart with Admin and found resident's name and full code was listed. Review of facility policy, titled Advanced directives effective 04/2020 revealed upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Advanced directives will be uploaded into the Electronic Medical Record. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 675127 Page 2 of 2