Health inspection·July 12, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 out of 4 residents reviewed for clinical records (Resident #1). The facility failed to accurately document information for Resident #1 due to another Resident's name being present in care plan. This failure can place residents at risk of inaccurate needs or services based on comprehensive assessment. Findings included: Record review, dated July 12, 2023, of Resident #1's face sheet revealed a [AGE] year-old male admitted into the facility on [DATE]. Resident #1 diagnoses included but not limited to cerebral palsy (inability to control muscles), interstitial pulmonary (inflammation causing lungs to not get enough oxygen), Chronic Obstructive Pulmonary Disease,(COPD -Blockage of airway), Cystic Fibrosis (disorder that damagers lungs, digestive tract and other organs), Reduced mobility, unsteadiness of feet, cognitive communication deficit, dysphagia (difficulty swallowing), aphasia (loss of ability to understand speech), schizoaffective disorder; bipolar type, intellectual disabilities, muscle weakness, need for assistance with personal care. Record review of Resident #1's MDS assessment Section C-Cognitive Pattern, dated 7/10/23, revealed the resident was not assessed due to limited communication skills. Record review on 7/12/23 of Resident #1's care plan, dated 3/27/23, revealed a goal for PASARR indicating a positive screening. The information presented for the focus goal stated, I, [Resident] is receiving PASRR service through Texas Panhandle Services. [Wrong Resident] has a PASRR positive diagnosis Dx: IDD due to Cerebral Palsy. Case worker is [Employee] w/TPC. Incorrect name of resident identified in focus goal. Record review on 7/12/23 of Resident #1's care plan, dated 3/27/23 and revised on 6/7/23, revealed a goal for PASARR indicating a positive screening. The information presented for the focus goal stated, I, [Resident], is receiving PASRR service through Texas Panhandle Services. [Wrong Resident] has a PASRR positive diagnosis Dx: IDD due to Cerebral Palsy. Case worker is [Employee] w/TPC. Incorrect name of resident identified in focus goal. Interview on 7/12/23 at 3:01 PM, the MDS Coordinator confirmed that wrong resident name was care Page 1 of 2 675282 675282 07/12/2023 Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few planned. Stated and confirmed that the wrong name was put in the care plan. MDS Coordinator indicated that DSS is the employee who entered the goal. Interview on 7/12/23 at 3:13 PM, the DSS confirmed another name, [Resident], is in the care plan. DSS confirmed that another name was on both care plans completed. Negative outcome indicated by DSS could be records associated with wrong patient name and inaccurate information on the patients involved. Interview on 7/12/23 at 3:15 PM, the DON read care plan verbatim. Looked at 6/2023 showed had Resident #1 and [Resident] name in one chart. Negative outcome of two people's names, it's a care plan saying there's a wrong diagnosis. Instead of putting Resident #1, she said [Resident] has Cerebral Palsy as well and is primary diagnosis for PASARR positive assessment. They both have a diagnosis of Cerebral Palsy just wrong name was put in Resident #1 chart. 675282 Page 2 of 2