Health inspection·February 1, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 3 residents (Resident #'s 1, 3 and 5) reviewed for respiratory care. Residents Affected - Some The facility failed to ensure Residents #1, #3, and #5's nebulizer mask was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. Findings include 1. Record review of Resident #1's face sheet, dated 02/01/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dislocation of right hip, muscle wasting, cognitive communication deficit, dysphagia (swallowing difficulty), cough, asthma (inflammatory disease of the airways of the lungs). Record review of Resident #1's MDS Quarterly Assessment, dated 1/22/24, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Care Plan, dated 01/25/24, revealed the resident had an impaired respiratory status, her nebulizer therapy should administer as ordered by MD. Albuterol Sulfate Nebulization Solution, 3 milliliter inhales orally vis nebulizer three times a day for shortness of breath for 5 days. Start date 1/31/24. In an interview and observation on 02/01/24 at 9:40 a.m., Resident #1 was sitting in her wheelchair drawing, observed nebulizer cup and mask sitting on dresser not bagged. Resident #1 stated she had her last treatment last night, could not recall time. Resident #1 stated she never seen nurse bag the nebulizer cup and mask, stated it was just always placed on desk. 2. Record review of Resident #3's face sheet, dated 02/01/24, revealed a [AGE] year-old male who was admitted on [DATE] and re-admitted on [DATE]. Resident #3 had diagnosis which included acute respiratory failure (inadequate gas exchange), hypoxia (the body is deprived of adequate oxygen supply), shortness of breath. Record review of Resident #3's MDS Quarterly Assessment, dated 01/10/24 revealed a BIMs score of Page 1 of 2 675988 675988 02/01/2024 Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

F 0695 15, which indicated the resident was cognitively intact. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #3's Care Plan, dated 01/15/24, revealed the resident received Oxygen therapy for ineffective gas exchange. Albuterol Sulfate Nebulization Solution, 3 milliliter inhales orally vis nebulizer three times a day for shortness of breath for 5 days. Start date 1/31/24. Residents Affected - Some In an interview and observation on 2/1/24 at 10:20 a.m., Resident #3 was sitting in wheelchair visiting with a friend. Nebulizer was observed sitting on the nightstand, cup and mask not bagged. Resident #3 stated he had received his last treatment early this morning at 7:00 a.m Resident #3 stated that the staff never has bagged nebulizer cup and mask while not in use. 3.Record review of Resident #5's face sheet, dated 2/1/24, revealed a [AGE] year-old male, who was admitted on [DATE]. Resident #5 had diagnosis which included, Acute upper respiratory infection. Record review of Resident #5's MDS Quarterly Assessment, dated 01/18/24 revealed a BIMs score of 99, which indicated the resident is severely cognitively impaired. Non interview able. Record review of Resident #5's Care Plan dated 10/14/23, revealed the resident receives Ipratropium-Albuterol Sulfate Nebulization Solution, 3 milliliter inhales orally vis nebulizer every 4 hours for shortness of breath, and wheezing. Start date 10/16/23. Observation on 2/1/24 at 11:10 a.m., Resident #5 was sleeping in bed, observed Nebulizer on nightstand, cup and mask lying on floor next to nightstand not bagged. In an interview with the ADON on 02/01/23 at 4:00 PM, she revealed it was the policy and procedure for the floor nurse after administering treatment to wash nebulizer cup and mask after each use and place cup and mask in plastic bag. ADON stated the failure to store nebulizer cup and mask properly could result in infection control issues. Record review of the facility's policy Infection Control Considerations Related to Medication Nebulizer/Continuous Aerosol, dated November 2011, revealed in part: 1) Store circuit and nasal canula or mask in plastic bag between uses. 2) Change disposable parts (set-up) every seven (7) days and label with date. 675988 Page 2 of 2