Health inspection·June 12, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility transportation staff failed to ensure resident received adequate supervision and assistance devices to prevent accident for 1 (Resident #1) of 1 resident reviewed for accidents. The facility failed to secure Resident #1 in wheelchair while being transported in the facility van from dialysis. This failure could place residents in the facility who required assistive safety devices when traveling in the facility van at risk for accidents. Finding included: Record review of a facility investigation report dated 03/13/2023 indicated that Resident #1 wheelchair tipped backward, resident sustained superficial hematoma back of head, small skin tear to right elbow, and a small skin tear to back of right hand. Record review of Resident#1 face sheet revealed is [AGE] year-old, primary language English, date of birth [DATE]. admission date 01/06/2023 and was discharged on 4/15/2023 to home with home health service. admitted from an Acute care hospital: Diagnoses: Acute respiratory failure with hypoxia, pneumonia, unspecified organism, chronic obstructive pulmonary disease with acute exacerbation, other chronic pancreatitis, benign prostatic hyperplasia without lower urinary tract symptoms, , peripheral vascular disease (unspecified), type two diabetes mellitus with diabetic neuropathy (unspecified), hyperlipidemic (unspecified), dependence on renal dialysis, end stage renal disease, anemia in other chronic diseases classified elsewhere, essential ( primary ) hypertension, arthropathy (unspecified), muscle weakness ( generalized), sarcopenia, difficulty in walking, unspecified lack of coordination, acquired absence of right leg below knee, acquired absence of left below knee. Review of Resident #1's Plan of care indicated resident/resident representative has been informed of medical condition and plan of care: Admit to Skilled services, continue skilled services times five weeks' time thirty days for therapeutic exercise, therapeutic activities, neuro muscular re-education, safety, and Activities of daily living (ADL) training with use of modalities per protocol for pain and strengthening. 02/08/2023: Continue skilled physical therapy for five weeks' time thirty days for balance activities, gait/transfer training, and pain management. 01/06/2023: Dialysis-monitor AV Shunt/Fistula to (left inner forearm) for thrill and bruit every shift, notify MD (medical doctor), NP (nurse practitioner) for any unusual/ unexpected findings. Page 1 of 3 676025 676025 06/12/2023 Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652

F 0689 Level of Harm - Actual harm Residents Affected - Few Record reviewed of incident report dated 3/13/2023 at 4:37pm reflected: SN (Skilled Nurse) was notified by transportation driver that resident #1 received some injuries from a fall in the transportation van. Resident#1 assessed, 1.5cm x1.5cm skin tear to top of right hand between the 1st and 2nd proximal knuckles, 1.5cm x 1.5cm skin tear to top of right elbow with bruising around area and a raised area to the back of resident's head with some dry blood noted. Both skin tears cleansed, and Triple Antibiotic Ointment (TAO) applied along with steri-strips in place. Pressure applied to raised area to head. SN offered sending resident to hospital, resident refused and states I am fine, it's nothing big. Review of Medication order review dated 03/13/2023 reflected at 7:44pm Orders Administration Note: Acetaminophen-Codeine Tablet 300-30 milligram. Give 1 tablet by mouth every 6 hours as needed for Pain, may give 2nd tab if 1st tab is ineffective** no more than 3 grams of Acetaminophen in a 24-hour period. In an interview with LVN A on 6/6/2023 at 2:30 pm states Resident #1, was discharged on 4/15/2023 to home with home health service and (van driver) no longer work with at the facility. During an interview on 06/06/2023 at 2:45pm: Director of Nursing (DON) verified Resident#1 was discharged on 4/15/2023, and Facility Reported Incident occurred on 3/13/2023. Primary Care Physician (PCP), and spouse representative notified. Report review indicated on investigation summary Van Driver stated, she did not properly and safely secure resident prior to the transport. DON states (van driver) and staff, was in-serviced regarding Abuse/Neglect. Post incident (3/13/2023), DON states provider action: Transport driver, suspended times three days, given a written Corrective Active notice pending investigation, removed from transportation position, 3/16/2023 removed from suspension, she re-assigned to a Certified Nurse Aide(CNA), position, which was excepted by staff, but never pick-up any additional shifts. Record Review on 06/06/2023, Educational In-Service Regarding Transport Safety given on 3/13/23: Ensure resident is properly and comfortable seated. Lap belts and shoulder belts are tightened and securely fasted. Chairs are securely fastened with all straps; front and rear clamps are locked and in placed as chair is secured to the van floor. Chair brakes are locked. If a sling is used ensure it is snuggly draped over transport chair with non-skid mat in place. Monitor residents during transport. If a resident refused to all required safety. If a resident refuses to all required safety devices in place, do not transport, immediately report the concern to Administrator and or DON. Record Review of Investigation report dated 03/13/2023 revealed Transportation driver was returning Resident #1 from dialysis via transport van. While pulling into facility driveway incline, resident #1 wheelchair tipped backwards, Resident #1 sustained small superficial hematoma to back of head as well as small skin tear to right elbow and a small skin tear to back of right hand. Resident refused to be sent to Emergency Room. During an In a phone interview with Resident #1 06/08/2023 at 3:30pm, Resident#1 said, we usually use a Lap Belt but, was not use this time., my wheelchair (w/c) went backwards and flipped upside down, I tried to use my hands to catch myself, but I couldn't. Review of an undated policy and procedure for Facility Transportation indicated: Purpose, to indicate who is eligible to drive the facility owned van and for what reason the van may be utilized. Eligible Drivers: Only the employee of the facility, who have been approved by the central office and whose name appears on the driving list shall be authorized to drive the facility van on [NAME] fide 676025 Page 2 of 3 676025 06/12/2023 Autumn Leaves Nursing and Rehab Inc 321 Kilgore Drive Henderson, TX 75652

F 0689 Level of Harm - Actual harm Residents Affected - Few facility business. Resident needs to be met while out of the facility prior to being transported by facility personnel. Transportation Aide Responsibility to report all accidents and incidents while on a trip to the DON and Administrator. Review of the facility Abuse/ Neglect Policy dated 2023 reflected: POLICY STATEMENT; It is the responsibility of our facility employees/associates, consultants, attending physicians, family members, visitors, etc. to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriation of resident property to facility management. 676025 Page 3 of 3