Health inspection·August 28, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of five residents (Residents #1) reviewed for feeding tubes. The facility failed to provide treatment for Resident #1 dressing around g-tube site was labeled 08/20/23. The g-tube site was observed on 08/23/24. These failures could place residents at risk of infection. Findings included: Record review of Resident #1's face sheet dated 08/23/24 reflected the resident was a [AGE] year-old female with and admission date 06/02/21 and a readmission date of 08/07/24. Resident #1 diagnoses included: benign neoplasm of bones of skull and face (benign growths of bone that typically occur in the skull or jawbone), unspecified dementia, dehydration, and dysphagia-oral phase (difficult swallowing). Record review of Resident #1's Annual MDS Assessment, dated 08/13/24, reflected Resident and had BIMS score of 99 because resident was unable to complete interview. Section K swallowing/nutritional status reflected A) proportion of total calories the resident received through parenteral, or tube feeding is 51% or more. B) Average fluid intake per day tube feeding was 501 CC/day or more. Record review of Resident #1's care plan dated 08/14/24 reflected: Problems: [Resident #1] had a g-tube in place. Goals: [Resident #1] had a stable weight as evidenced by no significant weight loss of 5% or more in 30 days .Approach: Administer feeding via g-tube as ordered. Record review of Resident #1's Physician Orders report dated 08/23/24 reflected: Enteral Feeding: Tube site care. Once a day (10:00 PM-6:00 AM) every day and ordered on 07/17/24. Observation on 08/23/24 at 12:15 PM revealed Resident #1 g-tube site dressing had a date of 08/20/24. Interview on 08/23/24 at 1:47 PM with LVN A revealed overnight staff handled changing residents g-tube site dressing. LVN A revealed residents were at risk of developing an infection. Interview on 08/23/24 at 1:52 PM with LVN B revealed the overnight shift handled changing residents g-tube site dressing every day. LVN B stated residents were at risk for skin break down and Page 1 of 2 676067 676067 08/28/2024 Mira Vista Court 7021 Bryant Irvin Rd Fort Worth, TX 76132

F 0693 infection. Level of Harm - Minimal harm or potential for actual harm Interview on 08/23/24 at 2:10 PM with the DON revealed the treatment nurse handled changing g-tube site dressing Monday-Friday. She stated the overnight nurse handled changing the g-tube site dressing Saturday-Sunday. She revealed the electronic health monitoring system showed when task was needed to be completed in yellow, due in green and red when late. She revealed the tasked disappeared out of the system until the next schedule time. The DON stated she expected staff to check the g-tube site dressing when medication was administered. She stated residents were at risk of skin break down and infection such as yeast. Residents Affected - Few Interview on 08/23/24 at 2:32 PM with the Treatment Nurse revealed she just started last week and Monday the 08/19/24 was her first day doing wound care by herself. The Treatment Nurse stated she believed a different shift took care of the g-tube site dressing. The Treatment Nurse stated not changing the g-tube site dressing could have caused skin break down. Interview via telephone on 08/27/24 at 11:30 AM with Nurse Practitioner C revealed the g-tube site dressing should be changed daily. The Nurse Practitioner stated residents have a likely hood for infection, drainage when g-tube site dressings were not changed. The DON was asked to provide a copy of the electronic monitoring record for Resident#1 related to g-tube site care from 08/20/24 to 08/23/24; however, this was not provided to the investigator prior to exit. Record review of the facility's Gastrostomy Tubes policy, dated May 2023, reflected: .2. The patient/resident that is fed enteral methods receives the appropriate treatment and services to restore oral eating skills and prevent complications of enteral feeding . 676067 Page 2 of 2