Health inspection·July 13, 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 clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 2 of 3 residents reviewed for parenteral care and services: The facility failed to ensure there was documentation of the insertion of hydrodermoclysis (fluids infused into the subcutaneous tissue for hydration) clysis, monitoring of the site and the infusion and discontinuation of therapy. for Residents #1 and #2. This failure could affect residents with parenteral care and services, placing them at risk of peripheral edema, leakage, or fluid overload from hypodermoclysis hydration infusion. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was admitted on [DATE], was a [AGE] year-old male with diagnoses including acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood causing lack of oxygen supply), fracture right femur (broken upper leg), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and stroke (damage to the brain from interruption of its blood supply). Record review of MDS dated [DATE] indicated Resident #1 had severe cognitive impairment. He required extensive assistance in performing all activities of daily living (ADLs). He was in-continent to bowel and bladder. Record review of care plan for Resident # 1 indicated Focus: Resident had a cerebral vascular accident and goals that Resident will be free from signs and symptoms of complications of stroke including dehydration through review date. Record review of Resident #1's physician orders dated [DATE], indicated an order for Dextrose-NACl Intravenous Solution 5-0.45% (Dextrose w/ Sodium Chloride) inject 3 liters subcutaneously (via clysis) one time only for dehydration until [DATE]. Record review of Resident #1's progress notes dated [DATE] - [DATE], MARs for [DATE] indicated no documentation of the clysis needle being inserted, no monitoring/assessment of infusion, the site or discontinuing of the hydration. During an observation and interview on [DATE] at 8:45 a.m., revealed Resident #1 was lying in bed, Page 1 of 4 675540 675540 07/13/2023 Liberty Health Care Center 1206 N Travis St Liberty, TX 77575

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few fall mat by bed. He was clean and well-groomed with no unpleasant odors. Water was available at bedside, and he did not show any visible signs of dehydration. Resident #1 was not able to recall the hydration infusion he received in [DATE]. There was no infusion at the time of the observation. During an interview on [DATE] at 9:00 a.m., LVN A recalled administering Resident #1 hypodermoclysis (subcutaneous) hydration therapy, she said Resident #1 was bad about pulling the subcutaneous needle out and that the therapy would have to be restarted. She said staff would have to stay with the resident while he was receiving his infusion. LVN A said that the procedure was supposed to be documented in the progress notes or MAR every shift, the type of fluid, location of needle, insertion site assessment, monitoring infusion, and starting or discontinuing the infusion. LVN A felt the treatment benefits the residents if they were mildly dehydrated and stated, she was comfortable and competent in performing the procedure. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was admitted [DATE], was [AGE] years old and had diagnoses including cellulitis of left lower limb (a bacterial skin infection), acute embolism (blood clot or air bubble in artery), and thrombosis (blood clot) of other specified deep vein of left lower extremity, dementia (loss of cognitive functioning), developmental disorder of scholastic skills (conditions characterized by a significant discrepancy between an individuals perceived level of intellect and their ability to acquire new language and other cognitive skills), cognitive communication deficit (difficulty with thinking and how someone uses language). Resident #2 expired on [DATE]-23 Record review of MDS dated [DATE], he was alert with a Brief Interview for Mental Status (BIMS) score of 2 which indicated he was severely cognitively impaired. He required extensive assistance in performing most activities of daily living (ADLs) and supervision with eating and locomotion. He was in-continent to bowel and bladder. Record review of care plan for Resident # 2 indicated Focus: Resident is receiving IV fluids for peripheral line/PICC line/midline/central line) in the right/left arm). Decrease PO intake Date initiated [DATE]. Goals: Resident will be compliant with IV fluids thru next review. Resident will tolerate IV fluids with no complications thru next review. Record review of Resident #2's physician orders dated [DATE] indicated to infuse Sodium Chloride 0.9%, use 40 ml/hr intravenously one time for dehydration for 2 days x 2 Liters NS via clysis (1st Liter via emergency drug kit ekit) [DATE] to [DATE]. Record review of MAR and TARs [DATE] for Resident #2 indicated no documentation of insertion of the needle for the clysis, monitoring/assessment of parenteral care or discontinuation of therapy. Record review of Resident #2's progress notes for 7/2023, did not include documentation of insertion of the needle, monitoring of hypodermoclysis (subcutaneous) infusion, site care or management/monitoring. During an interview on [DATE] at 3:09 p.m., LVN C said she knew she was supposed to document insertion of the clysis needle and monitoring. She said she made sure Resident #2 had the order and just made the mistake and did not document about the administration or insertion of the clysis. During an interview on [DATE] at 3:45 p.m., LVN B said she had been checked off on inserting the clysis needle. She said the insertion was supposed to be documented, the site monitored and 675540 Page 2 of 4 675540 07/13/2023 Liberty Health Care Center 1206 N Travis St Liberty, TX 77575

F 0842 documented, and when the hydration is stopped, it should be documented in the medical record. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 8:10 p.m., LVN D said she discontinued Resident #2's clysis for hydration about 30 minutes into her shift on [DATE].She said she should have documented the discontinuation and what the site looked like. Residents Affected - Few During an interview on [DATE] at 10:20 a.m., the DON said that all staff were trained upon hire and annually on the Hypodermoclysis - Subcutaneous Hydration therapy, this training/in-service included purpose, general guidelines, equipment/supplies needed, steps in procedure, documentation, and reporting. The DON and ADM stated their expectations were for staff administering subcutaneous hydration therapy to be trained and competent and to document the procedure following the facility policy in the resident's medical records. Negative outcome regarding improper or lack of documentation regarding subcutaneous hydration therapy could reflect inaccurate assessment of resident and possible complications at subcutaneous insertion site (peripheral edema, leakage of fluid, or fluid overload) - DON acknowledges that one of the reason they utilized clysis (subcutaneous) infusions for hydration therapy was the lack of potential serious complications like fluid overload and infected IV sites, states it was also easier for the residents. Record review of facility policy revised [DATE] indicated Hypodermoclysis - Subcutaneous Hydration . Purpose: . The purpose of this procedure is to provide guidelines for administration of subcutaneous hydration to the resident as ordered. General guidelines: . 2. Hypodermoclysis is a method of hydration that does not require an intravenous catheter for delivery. 3. Hypodermoclysis involves using small needles to deliver isotonic fluids (0.9 NS, lactated ringers, D%W) slowly into the subcutaneous tissue. 4. This system is designed for short-term, preventative hydration or for mild dehydration. 5. Hypodermoclysis is NOT for antibiotics, narcotics, or fluids with electrolytes (KCL, magnesium, etc.). 6. Sites for needle placement are the abdomen, stomach, and front or side of thighs. Less commonly used sites are the upper arm or upper back shoulder area. 7. The fluids infused into the subcutaneous tissue where it is absorbed slowly. While the fluid is absorbed, a fluid wheal will form. This is normal and is not an infiltration of fluids. 8. Hypodermoclysis reduces the chance of the following complications associated with intravenous therapy: a. fluid overload, CHF; b. Phlebitis; and c. infection. 9. Physician order should include: a. type and quantity of isotonic fluid; b. Rate (determined by type of delivery set); and c. length of treatment. Steps in the procedure: 1. Review physician order. 2. Explain procedure to resident. 3. Assemble fluid and kit. 4. Wash hands. [NAME] non-sterile gloves. 5. Prime tubing including attached needle set until all air is removed. 6. Do sterile site preparation and allow to air dry. 7. Pinch up skin or flatten skin. Insert needle strip flat into skin. 8. Secure needle strip to skin using transparent dressing. Tape tubing to skin. 9. Date dressing and tubing. 10. Start fluid and adjust flow rate. Make sure that the resident is comfortable. 11. Monitor for fluid wheal will form. This is normal and is not an infiltration of fluids. 12. If necessary, the site may be lightly massaged to help fluid absorption. 13. Observe for any signs of peripheral edema (not the fluid wheal), leakage or fluid overload. Monitor for line disconnection from skin. 14. If the site needs to be changed, the whole set including needles are changed as one piece. Contact pharmacy for new set. No new order is needed. Documentation . 1. Document the following in the resident's medical record upon insertion: a. procedure; b. type of fluids; and c. dressing and tubing. 2. Document the change date on the medication administration record. 3. Document the following in the resident's medical record every shift: a. the type of fluids being infused, location of needle placement, type of antiseptic used to clean skin; b. intake and output totals; c. time fluid bag was started and discontinued; d. condition of skin where needles are inserted, any leakage, peripheral edema (not fluid wheal), statement from resident regarding how they are tolerating treatment; e. date and 675540 Page 3 of 4 675540 07/13/2023 Liberty Health Care Center 1206 N Travis St Liberty, TX 77575

F 0842 Level of Harm - Minimal harm or potential for actual harm time of tubing and needle strip site change and reason for changing site (leakage, skin irritation, 72 hour site change); and f. Any communication with physician about problems, laboratory values. Reporting . 1. Report to physician or supervisor any information about treatment. 2. Report to oncoming shift nurses the type of treatment. Needle insertion site any complications, and any objective information concerning treatment. Residents Affected - Few 675540 Page 4 of 4