Health inspection·August 21, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for 1 of 18 residents reviewed for following physician orders. (Resident #11) Residents Affected - Few The facility did not change the dressings to Resident #11's drains every day as ordered. This failure could place the residents at risk of infection and the drain sites not healing. Findings included: Record review of physician orders dated August 2024 indicated Resident #11, re-admitted [DATE], was a [AGE] year-old male with diagnoses of kidney stones and retroperitoneal abscess (an unusual type of abscess [a confined pocket of pus] that occurs in the retroperitoneal space [the tissue that lines the abdominal wall and covers the abdominal organs]).The consolidated orders indicated The drain sites were to be cleaned with normal saline, pat dry, apply topical antibiotic ointment and cover every day until drains are removed. Record review of the most recent significant change MDS assessment dated [DATE] indicated Resident #11 was recently re-admitted to the facility on [DATE] and had a BIMS score of 15 (cognitively intact). The resident had an impairment in range of motion to the upper and lower extremities bilaterally, had an indwelling catheter/nephrostomy (surgery to make an opening from the outside of the body to the renal pelvis used to drain urine) and a diagnosis of retroperitoneal abscess. Record review of a care plan updated 08/20/24 indicated Resident #11 had drains to the left lower back. The goal was for the resident to have no complications. The interventions indicated to perform treatment to drain sites as ordered. During observation and interview on 08/19/24 at 9:14 a.m., Resident #11 said he had been in and out of the hospital for kidney stones and an abscess to his kidney. The resident had 2 long slender white tubes with a drainage bag attached to each tube. One drainage bag had a clear yellow fluid, and one drainage bag had a scant amount of dark yellow fluid. During an interview on 08/19/24 at 9:26 a.m., LVN A said Resident #11 had kidney stones and went in the hospital for removal of the stones with a stint put in. The resident then went back in the hospital for pain and the surgeon removed more stones and replaced the stints. The resident returned and after several days he began having pain and a knot appeared on his left lower back, so he was sent back out to the hospital. He said they learned the surgeon had cut his kidney during the procedure Page 1 of 2 676122 676122 08/21/2024 Oak Grove Nursing Home 6230 Warren St Groves, TX 77619

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and an abscess formed. The surgeon had to remove the abscess and put drains in to assist with healing. He said the resident saw the urologist last week, but they did not remove the drains. LVN A said one of the drains went directly into Resident #11's abscess and one drain went directly into the kidney. During observation and interview on 08/20/24 at 10:15 a.m., LVN A adjusted Resident #11 for wound care. There were 2 drain sites covered with gauze. Both gauzes were dated 08/17/24. LVN A said the gauzes were dated 08/17/24. He said he got busy yesterday on 08/19/24 and did not change the drain dressings as ordered. He said he did not work on 08/18/24, LVN B worked on 08/18/24. He said the possible negative outcome of not changing the dressing as ordered would be infection to the drain sites. The urine to the drainage bag from the kidney was clear yellow. The kidney drainage site was clear without signs of infection. The drainage bag from the abscess site had a scant amount of dark yellow drainage. The abscess insertion site was clear and without signs of infection. The resident denied pain to either drain site. During an interview on 08/20/24 at 10:38 a.m., LVN B said she changed the drain dressings for Resident #11 on Saturday 08/17/24 but did not change the dressings on Sunday 08/18/24. She said she had a lot of stuff going on lately and just forgot. She said the possible negative outcome of not changing the drain dressings could be infection to the drain sites. During an interview on 08/20/24 at 2:52 p.m., the DON said her expectations were for the wound care to be performed as ordered. She said the possible negative outcome would be Resident #11 could get an infection. Record review of a Dressing, Dry/Cleanpolicy revised September 2013 indicated: Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Preparation: 1. Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol.) 2. Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. Reporting: 1. Notify the supervisor if the resident refuses the dressing change. 2. Report other information in accordance with facility policy and professional standards of practice. Record review of a Nephrostomy Tube, Care of policy revised October 2010 indicated: Purpose: The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Preparation: 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 676122 Page 2 of 2