Health inspection·February 29, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 5 resident's reviewed for care plans. (Resident #1) The facility failed to ensure Resident #1's general surgeon (medical doctor) was informed of her care, as a follow-up appointment was missed and not rescheduled. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: Record review of Resident #1's face sheet, printed on 02/29/24, indicated she was a [AGE] year old female, originally admitted to the facility on [DATE]. Her diagnoses included perforation of intestine (a hole in the intestine that can cause stool to leak into the abdomen), chronic kidney disease stage 4 (severe loss of kidney function), down syndrome (a genetic condition that causes mild to significant physical and developmental problems), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #1's admission MDS assessment, dated 01/09/24, indicated she had a BIMS score of 10, which indicated moderate cognitive impairment. She was usually able to make herself understood and usually able to understand others. She did not exhibit behaviors of rejection of care or wandering. She had a surgical wound that required surgical wound care. Record review of Resident #1's care plan initiated on 01/23/24, and last revised on 02/28/24, indicated a focus of has alteration in skin integrity as evidenced by surgical wound to abdomen. The interventions included: * Assess for possible reasons for skin concerns, report findings to MD * Keep MD and RP informed of resident's progress * Monitor area for increased breakdown, signs/symptoms of infection, report to MD Record review of Resident #1's hospital after visit summary, dated 01/22/24, indicated she had a post-op appointment scheduled on January 25th, 2024 with the general surgeon that performed her Page 1 of 3 675814 675814 02/29/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0656 abdominal surgery during the hospitalization. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's hospital after visit summary, dated 01/30/24, indicated call [general surgeon], MD in 1 week(s). the summary further indicated Please notify [general surgeon] of any issues or concerns with the wound. Residents Affected - Few During an interview on 02/29/24 at 1:00PM, the DON said as far as she was aware Resident #1 did not go to a follow up appointment with her general surgeon. She said Resident #1 missed her 3 week follow-up appointment with the general surgeon because it was not on her hospital discharge orders from 01/30/24. She said since the appointment was not on her new discharge orders she did not expect for the resident to go to a follow-up with the abdominal surgery doctor. She said the wound care doctor was her first line for wounds and she would not expect to send Resident #1 to the general surgeon unless there was a significant issue. She said even though the surgical wound was open and being treated by the wound care doctor she did not reach out to the surgeon to notify him or schedule a follow up. During an interview on 02/29/24 at 1:35PM, LVN C said she was responsible for scheduling residents' outside appointments. She said Resident #1 had a follow-up scheduled with the general surgery office for January 25th, 2024 and the resident did not go to that appointment because she returned to the hospital on that day. She said the resident's family called and cancelled the appointment because the resident was in the hospital. She said rescheduling the appointment was missed. She said she thought it was important for Resident #1 to make it to her surgical follow up appointments. She said by missing the appointments Resident #1's condition could have worsened and her overall status could have worsened. During an interview on 02/29/24 at 1:44PM, Certified Medical Assistant D said she worked at the general surgeon's office. She said the office expects the patients to make it to their follow up appointments because the doctor likes to follow up on surgical wounds. She said she expected the facility to reach out and let them know of the reason for missing the appointment and then reschedule when possible. During an interview on 02/29/24 at 2:00PM, the DON provided the hospital after visit summary dated 01/30/24. She said the after visit summary from 1/30/24 indicated call [general surgeon], MD in 1 week(s). She said those statements she sees as telling the facility to take care of the specific problem. She said sometimes the after visit summaries say call primary care doctor and they have a primary care doctor in house that they would use instead of an outside doctor. She said even though the discharge paperwork said contact the general surgery MD she expected her staff to not contact the surgeon because the wound care doctor was taking care of the wound. She said the facility did not have a policy that addresses the making of appointments and making sure that follow-up appointments are not missed. She said we are not regulated to have a policy on that so we do not have one. During an interview on 02/29/24 at 2:18PM, Practice Manager E said she was the practice manager at the general surgeon's office. She said the general surgeon was unavailable for comment at that time. She said she expected the facility to keep a follow up appointments with the surgeon and reschedule if needed. During an interview on 02/29/24 at 4:18PM, LVN F said he thought residents with follow up appointments should go to the appointment. He said if an appointment was missed then he would contact the surgeon's office and ask if they still want the resident to have the appointment or not. He said he 675814 Page 2 of 3 675814 02/29/2024 Arbor Grace Guest Care Center 2700 S Henderson Blvd Kilgore, TX 75662

F 0656 would also contact the primary doctor and ensure everyone was on the same page. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/29/24 at 4:20PM, ADON B said someone should have followed up with Resident #1's surgeon to see if he still wanted her to come to the appointment after her hospitalization. She said the risk to Resident #1 was an adverse situation such as an infected wound and prolonged healing. Residents Affected - Few During an interview on 02/29/24 at 4:24PM, ADON A said she expected someone to follow up with the surgeon after Resident #1 returned to the facility from her hospitalization to see if the surgeon still wanted the follow-up appointment or not. She said the admitting nurse was responsible for making the appointment. She said if the admitting nurse was unable to make the appointment, then the next day shift nurse was responsible for ensuring the appointment was made. She said the risk to the resident not having a follow up appointment with the surgeon was a possible wound infection. During an interview on 02/29/24 at 4:29PM, the Administrator said he expected the staff to at least call the surgeon's office to see if they still wanted a follow-up appointment. He said the risk to the resident because she did not have a follow up appointment was a possible infection. 675814 Page 3 of 3