Health inspection·October 3, 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 observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurate for 1 of 6 residents (Resident #1) reviewed for accuracy of records. The facility did not document in Resident #1's medical record that resident suffered a second fall in early September 2023. This failure could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. The findings were: Record review of Resident #1's face sheet, dated 10/03/23, and EMR (electronic medical record) revealed a 53-year- old male admitted to the facility on [DATE] with diagnoses which included: (current) diabetes 2, nausea with vomiting, unspecified; other: hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness one side of the body), and cerebral infarction (stoke). Resident #1's Advanced Directive was Full Code. RP (responsible party) was listed as: the resident. Record review of Resident #1's admission MDS (minimum data set) assessment, dated 09/11/23 , revealed, o BIMS (brief interview of mental status) Score was 08 out of 15, which indicated moderate cognitive impairment. o ADLs (activities of daily living): B/B (bowel and bladder) continent of both, transfer was extensive with one staff assistance; bed mobility was extensive with one staff assistance; feeding was independent. ROM (range of motion) impairment upper left side. Record review of Resident#1's MAR (medication administration record), dated September 2023 revealed, gabapentin 300 mgs twice per for diabetes neuropathy, Zoloft 100 mg once per day for depression, trazadone 100 mg at night for depression (Medications that could create sedation). Record review of Resident#1's Skin Assessments revealed : 09/01/23 -skin intact. 09/08/23-skin intact. 09/15/23-skin intact; all available skin weekly assessments revealed skin was intact. Record review of Resident #1's Fall Risk Score (dated 8/31/23) revealed, a rating of 16 (high risk Page 1 of 3 675295 675295 10/03/2023 Lytle Nursing Home 15366 Oak St Lytle, TX 78052

F 0842 for falls). Level of Harm - Minimal harm or potential for actual harm Record review of Resident# 1's Care Plan, dated August 2023, revealed, the goals and interventions around fall prevention included: Residents Affected - Few *Fall prevention; 09/23/23-unwitnessed; found laying on side of bed. Intervention: floor mat. Neuro checks and vitals done. *Fall: (early September 2023-found on the side of bed; intervention was a scoop mattress. Record review of Resident #1's incident reports revealed no documentation of the fall in early September 2023. Record review of Resident#1's Nurse Note, revealed,: Note dated 10/01/23 revealed an unwitnessed fall. Resident was found by a CNA on floor next to bed. Resident's neuro checks and vital signs were negative. [There were no other documented notes of Resident #1 having another fall in early September 2023], or other diagnostic assessments completed. Also, no documentation could be found in the medical record that the physician or family were notified by the facility of the resident's fall in early September 2023.] During a telephone interview on 10/02/23 at 6:06 PM, Family Member A expressed the concern that the facility was not addressing Resident #1's fall risk. Family Member A could not remember how many times the facility made notice of the fall to family member; although the resident was the RP. Family Member A did not provide any information on how the facility was not addressing Resident #1's falls. During a telephone interview on 10/02/23 at 6:30 PM, Family Member B stated that Resident #1 had five to six falls since admission. The falls had occurred in the bathroom, shower, and room. Family Member B added, Resident #1 was impaired to one side. The injuries from the falls were not assessed by the staff. Family Member B stated the fall incidents were not documented in the medical record; and fall prevention measures were not implemented by the facility. Observation and interview on 10/03/23 at 9:50 AM revealed Resident #1 was in bed watching TV; alert and oriented person and place Low bed and one floor mat was present. Resident #1's call light was within reach and the room was clutter free. Resident #1 had a contracture to left hand. No skin tears or bruises present. Scoot mattresses present with cushion on left side. Bed was adjacent to the wall. Resident #1 stated, .I have fallen about 4 times .first fall was from a wheelchair in my room .I was trying to get out of my bed .I did not ask for help .no major injury except pain about two weeks ago .second fall was about 2 weeks ago .I was going to the rest room with a CNA .the CNA did not lift me correctly and fell [resident did not explain was the correct way of lifting .third time I tried to use the rest room and the CNA did not hold me correctly and fell .no injuries .last fall was when fell from wheelchair to bed [10/03/23] .I did not ask for help .they put a cushion to my mattress yesterday to my scoop mattress .never hit my head in my falls .I called for help and it took about 20-30 minutes for staff to respond .I had to scream for help .they checked me out and need to go to hospital .a little blood around my lip .no pain .no injury to my face or head .they have told me to call for help and use the call light. During an interview on 10/03/23 at 1:40 PM, LVN C stated: she provided treatment to Resident #1 for the past month. The resident had two falls unwitnessed without injury; and he could explain the 675295 Page 2 of 3 675295 10/03/2023 Lytle Nursing Home 15366 Oak St Lytle, TX 78052

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few falls. No need for ER visit; neuro checks and vitals were taken for 72 hours after every fall unremarkable. LVN C was not certain whether the falls and interventions were documented in the medical record. During an interview on 10/0323 at 2:00 PM, CNA D stated: she helped with ADLs to Resident #1 to include transfers and mobility. CNA D recalled Resident #1 one-time loss his balance in the bathroom, fell and did not have injury.[CNA D only provided supervision and did not physically put a gait belt around the resident or held the resident] CNA D could not remember whether the latter fall was documented in the medical record or whether she informed the nursing staff of the fall in the bathroom. During an interview on 10/03/23 at 3:03 PM, the ADON stated the resident had a fall early September 2023 but it was not documented by nursing staff. Not documented in the nurse's notes. The ADON added, the entire incident report or the neuro-checks or vitals were not found for the fall in early September 2023. The ADON added that the former DON was responsible for accuracy of the medical record for Resident #1. The ADON restated that no documentation was found of the first fall in early September 2023. [The facility did not have a DON at that time] The ADON did not provide information on the exact number of falls the resident experienced since there was a facility failure to document in the medical record. According to the ADON, regardless of the number of falls Resident #1 experienced evidence revealed (vital signs, neuro-checks and skin assessments, R#1 had no injuries; except cut lip on the last fall on 09/23/23. The facility expectation was that all falls be documented in the medical record, the ADON stated. During an interview on 10/03/23 at 3:27 PM, the NP stated he had not been informed by the facility when resident had a fall in early September 2023. The NP stated the facility might have called the MD on call. During an interview on 10/03/23 at 4:37 PM, the Administrator stated: he was new and could not explain why the facility had an inaccurate clinical record involving Resident #1. Record review of facility's fall prevention policy dated March 2028 read: .the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 675295 Page 3 of 3