Health inspection·June 3, 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 observation, interview, and record review, the facility failed to immediately notify resident's family/representative(s) when a significant change in condition that required hospitalization occurred for 1 or 3 (Resident #1) residents reviewed for change of condition. The facility failed to notify Resident #1's family/POA when he was admitted to the hospital for serious medical complications for more than 24 hours after he was admitted . This failure could place all residents at risk for not having their family or legal representative notified when having a change in condition. Findings included: Record review of Resident #1's Face Sheet, dated [DATE], revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses were noted as Non-ST Elevation (NSTEMI) Myocardial Infarction (type of heart attack involving a partly blocked coronary artery [surround the heart] that causes reduced blood flow), Thromboangiitis Obliterans or Buerger's Disease (disease that affects blood vessels in the body, most commonly in the arms and legs, causing vessels to swell which can prevent blood flow), Type II Diabetes Mellitus (Chronic disease in which your blood glucose or blood sugar, levels are too high) with Hyperglycemia (high blood glucose), End Stage Renal Disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Chronic (long-term) Pulmonary Edema (condition caused by too much fluid in the lungs), Kidney Transplant Status (has received a kidney transplant), Chronic (long-term) Obstructive Pulmonary Disease (diseases that cause airflow blockage and breathing-related problems), Acquired Absence of Left Leg Below Knee (surgically amputated), and Dependence on Renal Dialysis (treatment to clean your blood when your kidneys are not able to). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 05 which indicated a severe cognitive impairment. Functional status in Section G of the MDS indicated Resident #1 required extensive assistive and total dependence with daily living activities of personal care. Resident #1 required extensive assistance with the assistance of at least two staff to move to and from a lying position in bed or turn from side to side. Resident #1 required total staff assist to transfer from his bed to a wheelchair or bed . Record review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 had renal failure due to end stage kidney disease and had the need for hemodialysis every Monday, Wednesday, and Friday. Page 1 of 3 675593 675593 06/03/2023 Wisteria Place 3202 S Willis St Abilene, TX 79605

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The care plan revealed Resident #1 had impaired circulation due to diabetes, infections, Buerger's Disease, PVD, and CAD. During an interview on [DATE] at 3:15 p.m., the DON said she was aware Resident #1's family had not been notified when Resident #1 had been sent out to the hospital on the morning of Monday, [DATE] . The DON said on [DATE] at approximately 1:30 p.m., the Infection Control RN had informed her she had not contacted the family immediately after Resident #1 had been transported to the hospital. The DON said Resident #1 had been transported to the ER due to edema and shortness of breath at approximately 9:10 a.m. on [DATE]. During an interview on [DATE] at 4:10 p.m., the Infection Control RN said she had been at the facility for approximately two (2) years. The Infection Control RN said she was on duty and the nurse who made the decision to send Resident #1 out to the ER on [DATE]. The Infection Control RN said she entered Resident #1's room and observed his face and arms to be swollen and made the determination to call the paramedics to transport Resident #1 to the hospital. The Infection Control RN said she contacted his physician, the DON, the Dialysis Provider, and the Administrator. The Infection Control RN said she did not contact the family of Resident #1 immediately because she became busy checking the vital signs of another resident, received a personal phone call, and became distracted and overlooked calling the family. During an interview on [DATE] at 4:32 p.m., Resident #1's Family Member A said Resident #1 was sent to the hospital on the morning of [DATE], which was Monday, at approximately 9:30 a.m. and he was not notified until Tuesday morning ([DATE]). Resident #1's Family Member A said a member of his family was first notified by the hospital that Resident #1 had been admitted to the hospital. Resident #1's Family Member A said the nursing facility contacted his family member several hours after the hospital had call to notify the family Resident #1 had been sent out to the hospital the morning of [DATE]. Resident #1's Family Member A said he was upset because Resident #1 could have died and he would have not known until 24 hours later. During an observation on [DATE] at 9:05 a.m., Resident #1 was observed in the ICU unit of the local hospital. Resident #1 was lying in a hospital bed on his back and wearing a lightweight oxygen tube in his nose. Observed an intravenous (into or within the vein) pole by his bed with an intravenous bag attached. Resident #1 was observed with his eyes closed, grimacing, and moaning. During an interview on [DATE] at 9:15 a.m., ICU RN said Resident #1 was moved to ICU from the third floor of hospital on [DATE] due to unstable blood pressure and unsteady cardiac rhythm. During an interview on [DATE] at 9:45 a.m., Resident #1's Family Member/POA said she was Resident #1's responsible party and Power of Attorney for his medical care. Resident #1's Family Member/POA said she had received a call on Tuesday, [DATE] at approximately 10:00 a.m. from the local hospital requesting permission to complete a medical procedure on Resident #1. Resident #1's Family Member/POA said she was not aware Resident #1 was in the hospital at the time of the call. Resident #1's Family Member/POA said she was not contacted by the nursing facility until approximately 2:00 p.m. on Tuesday, [DATE]. Resident #1's Family Member/POA said the Infection Control RN called her and explained that Resident #1's blood pressure had dropped the morning of Monday, [DATE] and he was sent to the hospital by ambulance at approximately 9:30 a.m. Resident #1's Family Member/POA said the Infection Control RN told her she was the nurse who made the decision to send Resident #1 to the hospital by ambulance. Resident #1's Family Member/POA said the Infection Control RN said she had prepared Resident #1 to go to the hospital and then the Infection Control RN said she assisted another resident and 675593 Page 2 of 3 675593 06/03/2023 Wisteria Place 3202 S Willis St Abilene, TX 79605

F 0580 forgot to call Resident #1's family. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 1:15 p.m., the DON said the fact that the Infection Control RN did not contact Resident #1's family immediately after Resident #1 was transported to the hospital on [DATE] did not meet her expectation. The DON said with Resident #1's fragile medical condition, Resident #1 could have expired. The DON said she immediately took action and started an in-service to inform all staff that family/Responsible Party/POAs must be notified immediately when a resident was sent to the emergency room or hospital and she took disciplinary action against the Infection Control RN for her oversight. Residents Affected - Few Record review of the form, Counseling/Disciplinary Notice, dated [DATE] and signed by the Infection Control RN on [DATE] revealed the Infection Control RN was given a written warning for not notifying family when a resident was sent out to the hospital by ambulance. Record review of an In-service Attendance Record, dated [DATE], revealed the DON and ADON initiated an all-staff in-service training that informed staff, When a resident is sent out of facility family must be notified. No matter what the time of send out, a call is to be made to the emergency contact until they are reached and or the second contact is reached. Once family is contacted it is to be documented. Documentation should include the name of who you spoke with and what information was given. Record review of the facility policy, Resident Rights, not dated, revealed it was the policy of the facility to notify the family/responsible party of changes in the resident's condition and/or status. The charge nurse would notify the resident's family/responsible party when: (E). It was necessary to transfer the resident to a hospital. 675593 Page 3 of 3