Health inspection·October 7, 2024

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 4 of 5 Residents (#1, #2, #3, and #4) reviewed for hospice care: 4 of 5 residents receiving hospice services did not have a physician's order for hospice care. These problems could result in residents not receiving needed care as ordered by their physician. These problems had the potential to affect any resident receiving hospice care services. The findings included: Resident #1 Record review of the admission record for Resident #1, dated 10/07/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: Neuromuscular dysfunction of bladder (urinary problems), anemia (low red blood cells) and schizophrenia (chronic mental disorder). The face sheet revealed Resident #1 used Hospice Company A. Record review of the annual MDS for Resident #1, dated 07/05/24, revealed Resident #1 had a BIMS score of 06, which indicated severe cognitive impairment. Section O revealed Resident #1 was receiving hospice services. Record review of the care plan for Resident #1, last reviewed on 07/16/24, revealed a focus area for: Resident #1 has a terminal prognosis and/or is receiving hospice services, initiated on 01/15/24. Record review of the physician orders for Resident #1, dated 10/07/24, revealed no physician order for hospice care services. Resident #2 Record review of the admission record for Resident #2, dated 10/07/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: essential hypertension (high blood pressure), hyperlipidemia (too many fats in blood), and malignant neoplasm of bronchus or lung (lung cancer). The face sheet revealed Resident #2 used Hospice Company B. Page 1 of 3 676028 676028 10/07/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the quarterly MDS for Resident #2, dated 09/23/24, revealed Resident #2 had a BIMS score of 03, which indicated severe cognitive impairment. Section O revealed Resident #2 was receiving hospice care. Record review of the care plan for Resident #2, last reviewed on 09/26/24, revealed a focus area for: Resident requires hospice as evidenced by terminal illness, initiated on 10/07/24. Record review of the physician orders for Resident #1, dated 10/07/24, revealed no physician order for hospice care services. Resident #3 Record review of the admission record for Resident #3, dated 10/07/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: type 1 diabetes mellitus (chronic autoimmune disease), essential hypertension (high blood pressure), and dysuria (painful urination). The face sheet revealed Resident #3 used Hospice Company A. Record review of the quarterly MDS for Resident #3, dated 09/21/24, revealed Resident #3 had a BIMS score of 02, which indicated severe cognitive impairment. Record review of the physician orders for Resident #3, dated 10/07/24, revealed no physician order for hospice care services. Resident #4 Record review of the admission record for Resident #4, dated 10/07/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: COVID-19 (infection), chronic obstructive pulmonary disease (lung disease), and mood disorder. The face sheet revealed Resident #4 used Hospice Company A. Record review of the significant change MDS for Resident #4, dated 07/26/24, revealed Resident #4 had a BIMS score of 09, which indicated moderate cognitive impairment. Section O revealed Resident #4 was receiving hospice services. Record review of the care plan for Resident #4, last reviewed on 07/30/24, revealed a focus area for: Resident #1 has a terminal prognosis and/or is receiving hospice services with Hospice Company A, initiated on 08/01/24. Record review of the physician orders for Resident #4, dated 10/07/24, revealed no physician order for hospice care services. Record review of a facility document titled, Hospice Residents, provided on 10/06/24 revealed Residents #1, #2, #3, and #4 were listed. Interview on 10/07/24 at 11:44 AM, the DON stated residents and their families choose which hospice company to use and a hospice referral was made. The DON stated a physician order should be in the chart for hospice care services. The DON stated it was her responsibility to ensure residents receiving hospice care have a physician order for hospice. The DON stated she ran an order listing report every morning and reviewed the orders that were already in place. The DON stated she did not know why 676028 Page 2 of 3 676028 10/07/2024 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Residents #1, #2, #3, and #4 did not have a physician order for hospice care and stated it was not followed up on. The DON stated a potential negative outcome to the residents was not receiving hospice care when that was what the resident wanted. Interview on 10/07/24 at 12:09 PM, the Adm stated she expected a physician order to be in place for hospice services. The Adm stated the DON and the ADON's audit the charts and she did not know why these orders were missed. The Adm stated corporate nurses train the DON on their duties, so she does not know about the specific training for the DON. The Adm stated a potential negative outcome to the residents on hospice services were staff may not know which hospice company the resident used. Record review of the facility policy and procedure titled, Hospice Services, with a revised date of 02/13/07 reflected the following: As an end of life measure, the resident or responsible family member may choose to use hospice services within the facility . Procedures: 11. The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include: Physician Certification of Terminal Illness 676028 Page 3 of 3