Health inspection·October 19, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **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, the comprehensive person-centered care plan, and the residents' choices for 2 of 4 residents (Residents #1 and 2) reviewed for skin integrity. Residents Affected - Few Protective sleeves were ordered for Residents #1 and #2 after they each sustained skin tears but not applied. This failure placed residents at risk of further skin injury. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis dementia, rash and other non-specific skin eruption, anxiety disorder, and impulse disorder. Review of the quarterly MDS assessment for Resident #1 dated 08/24/23 reflected she could not participate in the assessment. It also reflected she required the extensive assistance of two + people for the activity of dressing. Review of the care plan for Resident #1 dated 06/05/23 reflected the following: Requires extensive assistance with ADLs, D/T weakness, confusion, vision problems. Resident will have her needs met through next review period. Observe/assess for changes in condition and report to MD if noted. Staff to anticipate needs and provide care as needed. Review of an incident report for Resident #1 dated 10/06/23 reflected the following: Nursing description: found skin tear to left arm, cleaned and dressed notified DON, MD, and family. Resident description: resident unable to give description. Review of the physician orders for Resident #1 reflected the following order dated 10/06/23: geri sleeve (protective sleeve) to both arms to prevent skin tears. Review of the October 2023 TAR for Resident #1 reflected no TAR item related to protective geri sleeves. Review of the undated face sheet for Resident #2 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia and anxiety disorder. Page 1 of 3 676117 676117 10/19/2023 Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the quarterly MDS assessment for Resident #2 dated 10/03/23 reflected she could not participate in the assessment. It also reflected she required the extensive assistance of one person for the activity of dressing. Review of the care plan for Resident #2 dated 09/25/23 reflected the following: The resident has a Skin Tear TO LEFT ARM. The resident will be free from skin tears through the review date. The resident's will Skin tear of the (location) will be healed by review date. Geri sleeves ordered. If skin tear occurs, treat per facility protocol and notify MD, family. Keep skin clean and dry. Use lotion on dry scaly skin. The resident needs protective sleeves for the arms. It also reflected (Resident #2) requires supervision-extensive assist with ADLs. Currently uses wheelchair at times. She refuses showers frequently. (Resident #2) will remain neat and clean through next review period. Dressing: requires staff x1 (one staff) for assistance. Geri sleeves ordered. DRESSING: Assist the resident to choose simple comfortable clothing that maximizes the resident's ability to dress self. Review of an incident report for Resident #2 dated 09/25/23 reflected the following: Nursing description: hospice CNA, notified this nurse that resident picked at skin and gave herself a new skin tear on left forearm. Assessment completed dressing applied MD, DON, and hospice notified. Resident description: resident unable to give description. Review of the physician orders for Resident #2 reflected the following order dated 09/25/23: GERI SLEEVE TO BOTH ARMS. Review of the September and October 2023 TARs for Resident #2 reflected no TAR item related to protective geri sleeves. Observation on 10/19/23 at 10:03 AM revealed Resident #1 laying in a geriatric chair outside of her room. She had three steristrips (thin strips of self-adhesive bandage) on her left arm covering a small wound. She was not wearing protective geri sleeves. Observation on 10/19/23 at 10:11 AM revealed Resident #2 in her room with two scratches on her left arm. She was not wearing protective sleeves. CNA B entered the room and prepared to assist Resident #2 with incontinent care but did not mention protective geri sleeves. Observation on 10/19/23 at 11:55 AM revealed Resident #2 in the dining room waiting for a lunch tray. She was not wearing protective geri sleeves. During an interview on 10/19/23 at 12:55 PM, CNA C stated she worked with Resident #1 and had never seen any protective geri sleeves for Resident #1. CNA C stated she did not think Resident #1 would take protective geri sleeves off if they were applied to her. CNA C stated she had never heard that Resident #1 ought to wear the sleeves. During an interview on 10/19/23 at 01:03 PM, LVN A stated Resident #1 had an order for protective geri sleeves, and the CNA made sure Resident #1 had them on. LVN A stated it was not a designated person who was responsible to apply the sleeves to Resident #1, but whoever was available to do it. LVN A stated the order for the sleeves was usually on the TAR, but she could not remember if she had been signing it off on the TAR. LVN A stated it was hard for them to keep the sleeves on Resident #1, as Resident #1 would always take them off. LVN A stated Resident #2 liked to pick at her skin and 676117 Page 2 of 3 676117 10/19/2023 Bertram Nursing and Rehabilitation 540 E State Hwy 29 Bertram, TX 78605

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had reopened a skin tear. She stated Resident #2 had an order for protective geri sleeves, and it was the responsibility of whoever got to it in the morning to apply them. She stated Resident #2 would not leave the sleeves on, though, and would always take them off. Observation on 10/19/23 at 01:11 PM revealed LVN A searched for protective geri sleeves in Resident #2's room and found one under some other items in a bedside drawer, but not a second. After searching all the available areas, no more sleeves were located in Resident #2's room. During an interview on 10/19/23 at 01:15 PM, CNA B stated Resident #2 had protective geri sleeves, but CNA B did not apply them, because she thought Resident #2 always removed them. Observation on 10/19/23 at 01:15 PM revealed CNA B applied protective sleeves to Resident #2's arms, and Resident #2 looked at her arms, raised them up, touched along the length of them, and gave two thumbs up signals. Observation on 10/19/23 at 01:20 PM revealed CNA C applied protective sleeves to Resident #1, who did not protest or struggle and did not immediately try to remove them. During an interview on 10/19/23 at 01:26 PM, the DON stated they had implemented protective sleeves after skin tears for Residents #1 and 2, because those residents had thin and tender skin. The DON stated the resident would not keep the sleeves on all day, but it was the responsibility for the CNAs to reapply them if they were removed. The DON stated the CNAs applied the sleeves, but it was the responsibility of the charge nurses to ensure the CNAs completed it. The DON stated the reason why the order was not being followed was her fault, because she did not add scheduling details when she entered it into the EMR system, so it did not show up on the TAR. The DON stated she put the order in and did not pay close enough attention to follow it up with the details, as she was very busy in that moment. She stated a possible negative impact on the residents would be they could sustain more skin tears. Observation on 10/19/23 at 02:46 PM revealed both Resident #1 and #2 were still wearing the protective sleeves and showed no sign of attempting to remove them. During an interview on 10/19/23 at 02:50 PM, the ADM stated ensuring treatment orders were properly entered was the responsibility of the charge nurses, and the DON was responsible for reviewing and follow up to ensure they were correct. The ADM stated her expectation was the nursing department would communicate about interventions for injuries, skin tears, and/or falls and make sure interventions were being applied. The ADM stated a potential negative outcome of the failure to apply protective sleeves to residents was they could continue to incur preventable skin tears. She stated if there were a resident who chose to refuse or remove the sleeves, that was his/her choice. Review of facility policy dated 10/05/16 and titled Skin Integrity Management reflected the following: 3. Wound care should be performed as ordered by the physician. 13. Skin injury due to friction and sheer forces should be minimized by the proper positioning, transferring, and turning techniques. In addition, friction injuries may be reduced by the use of lubricant and protective padding. 676117 Page 3 of 3