Health inspection·February 26, 2024

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 interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (R #1) reviewed for accuracy of records. The facility did not document R #1's urostomy bag was changed in the TAR on 01/24/24, 01/31/24 and 02/14/24. The facility did not document a for R #1's left ankle pain on 02/10/24. This failure could place residents at risk of not receiving adequate care and services due to inaccurate reflection of care provided. The findings included: Record review of R #1's face sheet reflected an [AGE] year-old male with original admission date of 01/23/24. His diagnosis included: Traumatic subarachnoid hemorrhage (brain bleed), type 2 diabetes, acute and subacute endocarditis (inflammation of the inner lining of the heart chambers and valves), hypertension, acute infarction of small intestine (loss of blood flow to the small intestine), peritoneal abscess (intra-abdominal collection of pus or infected material), postprocedural intestinal obstruction (blockage that keeps food or liquid from passing through your intestines resulting from a surgical procedure), and unspecified fall. Record review of R #1's MDS assessment dated [DATE] reflected a BIMS score of 8 (moderate cognitive impairment). MDS reflected R #1 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene. Record review of R #1's care plan dated 02/20/24 reflected the resident has a urostomy (abdominal wall opening that allows urine to leave the body through a stoma and without the need of a bladder). Date initiated: 01/25/24. The resident will not show signs or symptoms of urinary infection through review date. The resident will be/remain free from urostomy related trauma through review date. Interventions: Check tubing for kinks each shift. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD for signs/symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. Record review of R #1's TAR dated January and February 2024 reflected the order to change urostomy Page 1 of 3 676083 676083 02/26/2024 Brownsville Nursing and Rehabilitation Center 320 Lorenaly Dr Brownsville, TX 78520

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bag (once a week, clean skin with NS , dry with clean gauze and apply new urostomy bag, monitor and notify MD if noted redness, drainage from urostomy site, one time a day every Wednesday - start date: 01/24/24 at 8:00 AM). This was not documented as completed on 01/24/24, 01/31/24, and 02/14/24. R #1 also had an order to change urostomy bag (every 24 hours, as needed - start date: 01/24/24 at 10:45 AM) and there were no entries documented for between 01/24/24 (start date) and 02/21/24 (date TAR reviewed). Record review of R #1's order summary dated 02/21/24 reflected the orders: change urostomy bag (once a week, clean skin with NS, dry with clean gauze and apply new urostomy bag, monitor and notify MD if noted redness, drainage from urostomy site, one time a day every Wednesday) - start date: 01/24/24 and change urostomy bag (every 24 hours, as needed) - start date: 01/24/24. Record review of R #1's x-ray order dated 02/10/24 at 1:39 PM reflected an x-ray ordered for R #1's left ankle. Order scheduled by LVN A. Ordered by: MD. Record review of R #1's forms reflected no change of condition form for R #1's left ankle pain. Record review of R #1's progress notes reflected on 02/10/24, there was no progress note for when the x-ray was ordered or why the x-ray was ordered. Record review of R #1's x-ray results with date of exam: 02/10/24 reflected the findings suggest an old medial malleolar (the bump that protrudes on the inner side of your ankle) fracture. Record review of R #1's progress notes reflected on 2/13/24 at 10:39 AM, results of x-ray of left ankle reported to MD with new orders received to bandage left ankle and continue to monitor. Documented by RN B. Interview with LVN A on 02/23/24 at 3:20 PM. LVN A said she provided the care for R #1 as ordered, including changing the urostomy bag. LVN A said the urostomy bag was changed once a week at least, as it was ordered. LVN A said she changed the urostomy bag more frequently than once a week since R #1 voiced when R #1 wanted the bag changed. LVN A said on the days she worked that the bag needed to be changed, she changed the bag. LVN A said maybe she did not document the changing of the bag in the TAR, but the bag was changed. LVN A said R #1 had no signs of infection or indications that the bag was not being changed as ordered. LVN A said on 02/10/24, R #1 complained of pain to the left ankle. LVN A said she assessed the area and did not note swelling, bruising, redness, or any abnormality, but still she called the doctor, obtained orders, and followed through. LVN A said she did not complete a change of condition form although she probably should have. LVN A said she did not document a progress note, but she followed the protocol for the complaint of pain and just forgot to document. Interview with RN B on 02/23/24 at 4:15 PM. RN B said she provided the care for R #1 as ordered, including changing the urostomy bag. RN B said R #1 had the order to change the urostomy weekly on Wednesday and R #1 also had the order to change the bag as needed, so she would change the bag, usually as needed. RN B said she did remember changing the bag, but maybe she did not document in the EMR. RN B said R #1 would tell the staff if R #1 wanted the bag changed and R #1 was very vocal about things, so R #1 would have told them if the bag was not changed. RN B said R #1 had no signs of infection or indications that the bag was not being changed as ordered. RN B said on 02/13/24, she received the results for the x-ray to R #1's left ankle and she relayed the results to the MD. RN B said MD gave orders to wrap the ankle with an ace bandage as MD noted an old fracture. 676083 Page 2 of 3 676083 02/26/2024 Brownsville Nursing and Rehabilitation Center 320 Lorenaly Dr Brownsville, TX 78520

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with NP on 02/26/24 at 12:35 PM. NP said there were no indications that R #1's orders for changing the urostomy bag were not being followed as R #1 did not exhibit any signs/symptoms of infection or concern. Interview with DON on 02/26/24 at 1:00 PM. The DON said he was aware of the concern of lack of documentation for R #1. The DON said although there was no negative outcome for R #1, documentation must be accurate and complete to show the full picture of the care provided to R #1. The DON said if it was not documented, it did not happen, like they say in nursing. The DON said there were no indications that R #1 did not have the urostomy bag changed as there were no signs of infection or problems. The DON said there were no indications that the pain R #1 voiced to R #1's left ankle was not addressed as the x-ray was ordered and the results were received, then relayed to the MD. The DON said the issue was that there was a lack of documentation in the TAR, progress notes, and change of condition form. The DON said he completed a training on documentation sometime last month. The DON said he would complete another training specifically to address this concern. The DON said he spoke to R #1 and R #1 indicated the ankle fracture resulted from an incident many years ago, and there was no concern the old fracture resulted from the facility. Interview with ADM on 02/26/24 at 2:10 PM. The ADM said he was aware of the concern regarding that R #1 was missing documentation in the EMR. The ADM said there were no concerns that the treatments were not done or care was not provided, but the lack of documentation. The ADM said the facility would address this concern with an in-service. Documentation in Medical Record Policy date implemented 10/24/22 reflected Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 676083 Page 3 of 3