Health inspection·June 2, 2023

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 record review and interview, the facility failed to maintain clinical records on Resident #1 were complete, accurate, and in occordance with accepted professional standards and ptactice for 1(Resident #1) of 5 residents reviewed for accuracy and completness. The facility failed to document active treatment for Resident #1. This facility failure placed residents at risks for lack of appropriate interventions related to specific treatment. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] Diagnoses included myocardial infarction (a blockage of blood flow to the heart muscle) acute respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood) Rash and other nonspecific skin eruption, unspecified Dementia (memory loss), and Type 2 Diabetes (resist to insulin). Review of Resident #1's MDS dated [DATE] revealed Resident #1's BIMS summary score of 99. Resident # 1 is non-verbal. Review of Resident #1's care plan dated 9-8-2022 revealed Resident #1 focus documented pressure ulcer stage 3 to the posterior medial sacrum and posterior medial buttock.(full-thickness skin loss potentially extending into the tissue layer). Interventions continue current treatment as ordered, and change dressing PRN Q day Review of Resident #1's treatment administration record dated 5-28-2023 revealed Resident #1!'s treatment to clean on the posterior medial sacrum, apply anasept mixed with collagen, and cover with dry dressing Q day and PRN every day shift. Review of the treatment administration record revealed LVN A failed to sign off on treatment on May 11, 2023, May 19, 2023, and May 24, w2023. Interview was attempted on 05-27-2023 at 4:54 PM with Resident # 1. Resident #1 is nonverbal. Interview on 05-28-2023 at 12:45 PM with LVN A stated on the dates 5-11-2023, 5-19-2023, and 5-24.2023 she completed the treatment for Resident #1 but did sign off or document the treatment. LVN A stated the documentation should have been noted at the time of treatment. LVN A stated multitasking with other nursing duties she failed to document the treatment. LVN A stated it is important to sign Page 1 of 2 676047 676047 06/02/2023 Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few off and document progress notes to show the resident's condition. LVN A stated Resident #1 would not adversely be affected because the treatment was given but without documentation, it would break down communication between other nursing staff. Interview on 5-28-2023 at 1:17 PM with the Administrator stated the LVN A admitted to her on 5-28-2023 in the afternoon that she failed to sign off and document Resident #1's treatment. LVN A stated she failed to document the treatment as being called to other job duties. The administrator stated documentation should be done at the time of treatment and there was no excuse or reason the LVN A should not been able to document treatment for Resident #1. Interview on 5-28-2023 at 1:30 PM with the DON stated there was no reason why the LVN A was not able to document the treatment was done at the time treatment was given. The DON stated the LVN A had admitted to not documenting the treatment due to being called to other job duties. The DON stated that documentation is done at the time of treatment. Record review of the facility's charting and documentation policy dated Revised July 2017 stated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Record review of the facility's policy interpretation and Implementation dated Revised July 2017 stated documentation of procedures and treatments will include care-specific details including the date and time the procedure/treatment was provided, the name and title of the individual who provided the care, the assessment data and or any unusual findings obtained during the procedure treatment, how the resident tolerated the procedure treatment, whether the resident refused the procedure treatment, notification of family, physician, and the signature and title of the individual documenting. 676047 Page 2 of 2