Health inspection·July 21, 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, in that: The facility failed to ensure Resident #1's MPOA was notified that he had an increased oxygen demand to 8 LPM due to respiratory failure and Resident #1 passed away without his family present. 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 [DATE] reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (failure of lungs to provide adequate oxygen), dementia, chronic kidney disease (kidneys not working to clear toxins), COPD and heart failure. Record review of Resident #1's undated care plan reflected that Resident #1 had COPD and required a Bi-PAP and oxygen therapy and an intervention was give oxygen at 1 LPM - 5 LPM to keep oxygen levels above 92%. The next intervention was monitor for signs of respiratory distress and report to the physician. Record review of Resident #1's MDS dated [DATE] revealed in Section J Health Conditions that he was marked as not having shortness of breath or trouble breathing when lying flat, when sitting at rest or with exertion. Section C was blank for his BIMS score. In an interview on [DATE] at 11:30 am with FAM she stated she left the faciity on the evening of [DATE] after Resident #1 discharged from the hospital to the facility. She noticed Resident #1seemed anxious, and she wanted to give him time to settle back in at the facility, so she left and asked LVN A inform her once Resident #1 was settled or if anything changed. She stated she got a call around 4:00 am on [DATE] informing her that Resident #1 had passed away. In an interview on [DATE] at 1:40 pm LVN A stated Resident #1's FAM stated she was leaving and to let her know if anything changed with Resident #1. She stated she and the hospice nurse, RN B, went in to assess Resident #1 after he returned from the hospital and FAM left. She stated she did not Page 1 of 3 675525 675525 07/21/2023 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few recall if she notified her boss (DON) Resident #1 was close to the end of his life. She stated she last saw Resident #1 around 9:00 - 9:30 pm on [DATE] and he was ok. She stated she did not notify the FAM of Resident #1's increasing need for oxygen from 5 LPM to 8 LPM. She stated that she did not feel he had a change in condition, he had COPD and always had trouble breathing, and she was shocked when she learned that Resident #1 had passed a few hours after she left for the night (he passed [DATE]). She was aware of the policy to notify family members, the physician and the DON of a resident's change in condition. LVN A stated that on [DATE] the DON told her to add progress notes to Resident #1's medical record with a date of [DATE] because the resident passed away on the next shift after LVN A worked on [DATE]. Record review of Resident #1's progress notes revealed LVN A created a late entry progress note on [DATE] at 8:45 pm with an effective date of [DATE] at 4:30 pm stating the resident had labored breathing at his oxygen was 85% on 5 LPM of oxygen. Record review of Resident #1's progress notes revealed LVN A created a late entry progress note on [DATE] at 8:53 pm with an effective date of [DATE] at 5:15 pm stating the resident was placed on Bi-PAP, his oxygen was 86% and his respiratory (breathing) rate was 40. Record review of Resident #1's progress notes revealed LVN A created a progress note on [DATE] at 8:17 pm with an effective date of [DATE] at 6:40 pm and stated morphine and Ativan were administered to Resident #1 per RN B. In an interview on [DATE] at 3:10 pm with RN B she stated that on [DATE] Resident #1 was in respiratory distress that started when EMS transferred him from the stretcher to his bed. She stated that FAM went to pharmacy to get Ativan and morphine to make the resident comfortable, and the medicine was given when FAM arrived back at 6:30 pm. She stated that Resident #1's O2 was in the 80s, so oxygen was applied and titrated up to 8 LPM before she left around 8:00 pm and Resident #1's O2 was above 92% at that time. She denied notifying FAM of Resident #1's increased need for oxygen. Record review of Resident #1's hospice progress notes dated [DATE] that started at 4:20 pm and ended at 7:01 pm and were created by RN B, Resident #1's vital signs were documented as 99.8 degrees Fahrenheit temperature, a pulse of 99 beats per minutes, respirations at 40 breaths per minutes and described as regular easy at rest, blood pressure at 103/67, and oxygen at 82% on room air. RN B further documented in the hospice progress notes that Resident #1 was in respiratory distress upon his arrival (from the hospital via ambulance) and his oxygen was in the 60s initially on 5 LPM of oxygen, but after application of Bi-PAP it increased to the 80s. In an interview on [DATE] at 3:30 pm with LVN C he stated he checked on Resident #a few times and confirmed the Bi-PAP was on, and he was sleeping. LVN C stated around 4:30 am he went to check on Resident #1 and the resident was deceased and cooling; he notified hospice who told him to have the RN working pronounce him. He did recall LVN A telling him to notify FAM of any change in condition, but nothing changed on his shift. In an interview on [DATE] at 3:00 pm with DON she stated that she was not the DON at the time that Resident #1 was in the facility, but that her expectation was that nurses notify the family, the physician, and document for the 24-hour report any change in condition of a resident and that she considered the increase of oxygen from 5 LPM to 8 LPM a change in condition. In an interview on [DATE] at 9:55 am with MD she stated she was not notified of any changes in 675525 Page 2 of 3 675525 07/21/2023 Willow Park Rehabilitation Health Care Center 1000 Fm 3220 Clifton, TX 76634

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 after he was discharged from the hospital until after he was deceased . She stated she would expect staff to notify her of any major changes in condition for any of her patients such as a major increase in oxygen demand. Record review of Resident #1's progress note dated [DATE] at 4:25 am by RN D that stated: called to A Hall to pronounce Resident #1 deceased . Review of the facility's Change of Condition and physician/family notification policy revised on [DATE], revealed: Purpose: to ensure family and physician are notified of resident changes that fall under the following categories . significant change in physical condition Procedure: When any of the above situations exists, the licensed nurse will contact the resident's family and their physician 675525 Page 3 of 3