Health inspection·November 6, 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 in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy of records. The facility did not document nursing assessments, communications with nurse practitioner, orders received, or health progress for R #1's change (constipation) on 10/17/23. R #1 was diagnosed with constipation and a UTI. This failure could place residents at risk of not having an accurate representation of their medical condition and not receiving needed services. The findings included: Record review of R #1's file reflected [AGE] year-old male with original admission date of 10/22/22. His diagnosis included: Cerebral Palsy (A group of disorders that affect movement, muscle tone, balance, and posture), Intestinal obstruction, Hyperlipidemia, Hypertension, Gastro-esophageal reflux disease, Unspecified dementia, Heart disease, Osteoporosis, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, age-related physical debility, cognitive communication deficit, Dysphagia, and Severe intellectual disabilities. Record review of R #1's MDS assessment dated [DATE] reflected a BIMS score of 1 (severely impaired cognition). ADLs for bowel/bladder were always incontinent and was totally dependent. Record review of R #1's care plan dated 09/13/23 reflected R #1 had an alteration in gastrointestinal status related to history of intestinal obstruction. Date Initiated: 11/07/22. Interventions: Discuss with the resident/family/caregivers any concerns/fears/issues related to gastro-intestinal distress. Give medications as ordered. Monitor/document side effects and effectiveness. Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. Care plan reflected R #1 had an ADL self-care performance deficit related to physical limitations such as weakness, Cerebral Palsy, and Intellectual disabilities. Date Initiated: 10/22/22. Toilet use: The resident required assistance by 1-2 staff for toileting as needed. Monitor/document/report any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of R #1's file reflected no progress notes or change of condition forms for 10/17/23 when R #1 was noted to be possibly constipated by RN A, NP ordered a KUB and enema, and orders were carried out by RN A. Page 1 of 3 675635 675635 11/06/2023 Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520

F 0842 Level of Harm - Minimal harm or potential for actual harm Record review of R #1's vital signs for October 2023 reflected blood pressure was documented multiple times a day including on 10/17/23, 10/18/23, and 10/19/23 when R #1 exhibited changes in health. Pulse, respirations, temperature, and oxygen were only documented on 10/18/23, but not on any other day in October Staff interviews indicated vital signs should have included blood pressure, pulse, respirations, temperature, and oxygen. All vital signs should have been documented every day. Residents Affected - Few Interview with LVN A on 11/03/23 at 1:05 PM. LVN A said LVN A worked on 10/18/23 with R #1. LVN A said vital signs were checked every shift and as needed. LVN A said LVN A only documented vital signs if they were abnormal. LVN A said the vital signs included blood pressure, pulse, respirations, oxygen, and temperature. LVN A said LVN A checked R #1's vital signs during her shift on 10/18/23 but did not document the vital signs because they were normal. LVN A said LVN A checked R #1's vital signs again, closer to the end of the shift at around 9:30 PM and that was when R #1's oxygen was low. LVN A said LVN A did document those vital signs. LVN A said LVN A administered oxygen, notified the NP, obtained, and carried out orders. LVN A said LVN A documented the change of condition form and progress notes for the change on 10/18/23 which were noted in the EMR. Interview with LVN B on 11/03/23 at 3:00 PM. LVN B said LVN B worked on 10/18/23 with R #1. LVN B said vital signs included blood pressure, pulse, respirations, oxygen, and temperature. LVN B said the vital signs were taken for every resident on every shift and as needed if there were any changes. LVN B said the vital signs should always be documented, not just if something was abnormal. LVN B said if vital signs were taken, then the results should have been documented. LVN B said on 10/18/23 LVN B received the results of the KUB and reported them to the NP. LVN B said NP gave orders for R #1 to receive an enema and a laxative. LVN B said the results of the KUB showed minor constipation, but NP still gave those orders for R #1. LVN B said the orders and communications with NP were documented by LVN B in the EMR in a progress note. LVN B said LVN B went into R #1's room to carry out the orders and R #1 tolerated the enema and laxative well. LVN B said there were no concerns. LVN B said LVN B documented the orders in the EMR as a progress note, input the orders in the orders tab, and that LVN B carried out the orders. LVN B said constipation would be considered a change of condition and there should have been at least a progress note documented. LVN B said LVN B did not know why there was no note or form filled out for the reason the KUB was ordered and what was going on that led to that concern of constipation. LVN B said there should have been at least a note for the change of condition (constipation) R #1 had on 10/17/23 and the KUB being done. Interview with RN A on 11/06/23 at 11:00 AM. RN A said RN A worked on 10/17/23 with R #1. RN A said R #1 did not eat as well as R #1 usually did so RN A assessed R #1. RN A said R #1's bowels sounded sluggish, so RN A notified NP and received orders for a KUB and an enema. RN A said RN A carried out the orders but forgot to document a change of condition form or a progress note. Interview with DON on 11/06/23 at 1:35 PM. DON said vital signs included blood pressure, pulse, respirations, and temperature. DON said oxygen would not be included unless there was an issue or concern of oxygen. DON said if vital signs were taken, then the vital signs should have been documented. DON said the nurses would be the staff that took vital signs and if the nurses only documented if there were abnormal results, DON did not know that was how the nurses were documenting. DON said the vital signs should have always been documented. DON said documentation should have been done for any change to the resident's condition. DON said constipation was considered a change of condition. DON said there should have been at least a progress note documented for the change, the communication with the NP, the orders, and if the orders were carried out. DON said RN did not document the change of condition form and failed to at least document a progress note. DON said if staff did not document accurately or completely, the staff would not know the resident's 675635 Page 2 of 3 675635 11/06/2023 Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few baseline to compare the resident's current status to. DON said a possible negative outcome to R #1 would have been that the nurses would have not known R #1's medical condition or needs. DON said RN A did carry out the orders and addressed R #1's health but RN A failed to document. Interview with ADM on 11/06/23 at 2:20 PM. ADM said documentation was very important and that was why the facility began additional training for documentation. ADM said ADM was aware that RN A failed to document for R #1's change on 10/17/23. ADM said the facility completed an in-service with RN A. ADM said RN A addressed R #1's health concerns, notified NP, carried out the orders, but failed to document. ADM said there was verbal communication, but documentation was important because the resident's care must be documented based on the facility's policy. Record review of one-on-one in-service record dated 11/03/23 for topic: documentation on change in condition or receiving new orders. Summary of training session: educational counseling given to RN A on the importance of documenting in the EMR when a resident has a change of condition, or when receiving a new order. Record review of the Charting and Documentation Policy (revised 07/15) Policy Statement: Services provided to the resident, or any changes in the resident's medical or mental condition, should be documented in the resident's medical record. 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records. 4. Incidents, accidents, or changes in the resident's condition should be recorded. 675635 Page 3 of 3