Health inspection·November 10, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, psychosocial status and when there was a need to alter treatment significantly for 1 of 5 resident (Resident #1) reviewed for notification of changes. The facility failed to immediately consult with the resident's responsible party when Resident #1 expired. This failure could place residents at the risk of not being aware/informed of residents' condition. Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was discharged on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (cognitive loss) and pain. Record review of Resident #1's comprehensive MDS. dated [DATE], indicated the BIMS was 99, which indicated Resident #1's cognition was severely impaired. Resident #1 was received hospice services while a resident at the facility. Record review of a care plan for Resident #1, dated [DATE], reflected Resident #1's code status was DNR (Do not resuscitate). It Resident #1 was on hospice services dated [DATE]. Record review of Resident #1's Death Document, dated [DATE], reflected the following: Resident #1 date of admission: [DATE] at 4:50 PM and date of death : [DATE] at 06:18 AM. It further reflected person notified and physician notified date/time: [DATE] at 08:37 AM. During an interview on [DATE] at 10:00 AM with Family Member A stated she received a telephone call at 07:25 AM stating Resident #1 had expired. She stated when she arrived at the facility Resident #1's body was extremely cold. She stated she asked the ADON what time her mother was found. She stated she was told her mother was pronounced at 06:18 AM. During an interview on [DATE] at 01:10 PM with LVN B, she stated she worked 6AM to 6PM. She stated Page 1 of 3 676105 676105 11/10/2023 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few LVN B told her during shift report Resident #1 had expired and hospice was notified. She did not state what time the resident expired. She stated RN C pronounced Resident #1, but they were still waiting on hospice. She stated once she completed the shift report she went to Resident #1's room and CNAs were providing postmortem care for Resident #1. She stated she did not know who contacted the family. She stated the ADON came into the facility around 07:30 AM and the ADON called hospice and the family at that time. She stated when a hospice resident expired, they were to call hospice, the DON, and the ADM. She stated she did not call family or the physician. She stated it is her understanding that hospice will contact the family and physician. She stated she would document in the nurses notes in the residents' EMR. LVN A verified the date and time on the death document which stated the date of death was the time Resident #1 was pronounced. She stated she thought the notified date/time was the date and time hospice were notified. She stated the Death Document was to be completed by the charge nurse on duty. She stated she did not know why there was no documentation of Resident #1's condition in the nurses notes in Resident #1's EMR. During an interview on [DATE] at 1:35 PM with RN C, she stated she had worked the 6PM to 6AM shift on the morning Resident #1 expired. She stated she was not directly assigned to Resident #1 but was made aware the resident had expired. She stated she assessed Resident #1 and pronounced death at 06:18 AM. She stated she did not document anything other than the death document and she left the facility soon after because her shift had ended. She stated she did not know if the family was contacted when she left the facility. She stated hospice would let staff know who would notify family and physician. She stated documentation would be in the nurses notes in the resident's EMR. She stated documentation was the evidence of what happened, if you did not chart it, it did not happen. She stated she was not sure what time the family member arrived at the facility. During an interview on [DATE] at 01:51 PM with the ADON, she stated she came into the facility after Resident #1 expired. She stated she asked staff why hospice was not at the facility and was told hospice was notified and was on the way to facility. She stated she asked if the family was notified and was told no and she told them they needed to call family immediately. She stated she called the family at approximately 08:30 AM. She stated Resident #1 was pronounced at 06:18 AM by RN A. She stated the process when someone expired was the charge nurse to call the facility on call nurse and hospice. She stated hospice did not show up to the facility until approximately 08:15 AM after she called them. She stated she completed the Death Document. She stated the notified date/time was the time she notified the physician and family. She stated the date/time notified was [DATE] at 08:37 AM. She stated she did not document in Resident #1's EMR. She stated she did not know why the nurses did not document in Resident #1's EMR. She stated all staff were trained on the process when a resident expired. She stated normally hospice was notified and they made all the notification calls. She stated she had no idea why the family was not notified before she got to work. During an interview on [DATE] at 02:00 PM with the DON, she stated she spoke with hospice, and they stated hospice was notified at 06:18 AM of Resident #1 expiring. She stated the hospice nurse arrived at 07:25 AM and the funeral home arrived at 09:30. She stated the hospice nurse was in the facility from 07:25 AM until 09:30 AM according to hospice records. She stated there was no hospice documentation related to Resident #1 expiring. During an interview on [DATE] at 02:15 PM with the DON, she stated the process with hospice residents when a resident expired was, the charge nurse contacted hospice and hospice contacted the family. She stated all information related to the resident expiring should be documented in the residents' EMR. When asked why the documentation was not in the EMR she stated, lack of education. She stated the potential negative outcome could be delay in postmortem care and emotional damage to the family. 676105 Page 2 of 3 676105 11/10/2023 The Plaza at Lubbock 4910 Emory Lubbock, TX 79416

F 0580 She stated her expectations were for the physician, family, DON, and the ADM to be notified immediately. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE] at 02:30 PM with the ADM, he stated the process of notification of death of a hospice resident was the charge nurse was to contact hospice and hospice would notify the family, physician, and the funeral home. He stated he did not know why there was no documentation in the EMR related to Resident #1 expiring. He stated information related to Resident #1 death should have been documented somewhere. He stated he was not aware there were no hospice notes or nurse's notes. He stated the family should be notified immediately. He stated the potential negative outcome was going against resident and family rights. Residents Affected - Few During an interview with LVN D on [DATE] at 3:33 PM, she stated she was assigned to Resident #1 and was not made aware of any significant changes with the resident's condition when she assumed care. She stated the CNAs made rounds every 2 hours throughout the night and Resident #1 was sleeping when the 4:00 AM rounds were made. She stated Resident #1 was found deceased by the CNAs on their last round at around 6:00 AM. She stated she already gave report to the oncoming nurse when Resident #1 was pronounced deceased . She stated she thought the night RN was the one who pronounced the resident, but she was not sure. She stated she called hospice to notify them of Resident #1's passing before she left the facility and normally hospice called the family. She stated she did not know why there was no documentation in the nurse's notes. She stated she was sure she made an entry in the nurse's notes before leaving the facility, but she made the entry in the wrong EMR. She stated the family should be notified immediately of a resident's change of condition or death. Record review of the facility's policy titled Death of a Resident, revised date [DATE], reflected the following: Standard of Practice: Appropriate documentation shall be made in the clinical record concerning the death of a resident. Procedure: 4. The Nurse Supervisor/Charge Nurse will inform the resident's family of the resident's death Record review of the facility's, undated, document titled Death of a Resident, reflected the following: .2. Notify all appropriated individuals (Hospice if needed, MD, family, DON) 676105 Page 3 of 3