Health inspection·April 3, 2024

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 observations, interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #'1's electronic medical record did not reflect that an AED was used on Resident #1 when the resident coded. This failure could result in residents' records not accurately documenting life saving measure taken on the resident. Findings included: Review of Resident #1's electronic face sheet printed [DATE] revealed the resident was a [AGE] year-old female admitted to the facility [DATE] with diagnoses that included but not limited to fluid overload (a condition where you have too much fluid volume in your body), cerebral infarction (stroke), end stage renal disease (permanent loss of kidney function). Review of Resident #1's care plan initiated [DATE] revealed Resident#1 was full code. Review of Resident #1's nursing noted dated [DATE] at 6:38 AM authored by LVN A reflected: Upon rounding CNA notified nurse that patient wasn't breathing and no pulse. Nurse assessed and noted patient unresponsive. Code Blue initiated. Patient assisted to floor and CPR initiated with staff members, including nurses and CNA. 911 called, arrival within 5 minutes. Administrator, [Doctor] and family notified. Patient sent to [Hospital] ER via stretcher and 911 ambulance. Interview on [DATE] at 12:15 PM with CNA B revealed during rounds another CNA formed her that Resident #1 was not responsive. CNA B stated she informed LVN A that Resident #1 was not responsive and LVN A completed the assessment and CPR was began. CNA B stated there were several staff involved and one of the nurses did get the AED and it was used on Resident #1. Interview on [DATE] at 12:34 PM with LVN A revealed at the beginning of her shift on [DATE] she and the CNA were rounding, and she was alerted that Resident #1 was not responsive. LVN A stated she went to assess to the resident and determined she was not breathing. LVN A stated she checked Resident #1's code status which indicated she was full code and CPR was initiated. LVN A stated another nurse came in to help as well as other CNAs. LVN A stated the other nurse got the AED and they used it on Resident #1. LVN A stated the use of the AED should have been documented however everything had Page 1 of 2 675810 675810 04/03/2024 Lancaster Nursing & Rehabilitation 1515 N Elm St Lancaster, TX 75134

F 0842 happened so fast and she forgot. Level of Harm - Minimal harm or potential for actual harm Interview on [DATE] at 12:10 PM with the Director of Nursing revealed she worked with Resident #1 during the night shift of [DATE] and left during the morning shift of [DATE]. The Director of Nursing stated she last saw Resident #1 at 5:55 AM and she was on the phone and had been on the phone arguing the entire night. The Director of Nursing stated she left the facility around 6:10 AM and was called about an hour and 20 minutes and informed that Resident #1 had coded. The Director of Nursing stated she was not at the facility when live saving measures occurred however the AED should have been used and documented that it was used due to Resident #1 being full code. Residents Affected - Few Interview on [DATE] at 2:30 PM with the Administrator revealed the AED was used when Resident #1 coded because the pads had to be replaced the next day and it was still beeping from being used. The Administrator stated the use of the AED should have been documented in resident records however she did not think there was a risk to the resident due to the use of the AED not being documented. Review of the facility policy Automatic External Defibrillator, Use and Care of, revised [DATE], reflected: Complete a Defibrillation Event Report within 24 hours of the event. If the victim is a resident of the facility, document details of the event in the resident's medical record . 675810 Page 2 of 2