Health inspection·September 13, 2024

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 Based on observation, interview and record review, the facility failed to provide treatment and care to residents in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of 11 residents (Resident #1) reviewed for quality of care. Residents Affected - Few CNA L failed to ensure Resident #1 had catheter care on 08/20/2024 resulting in Resident #1's suprapubic catheter leak to go undetected, resulting in Resident #1 being left in a saturated brief and in a bed with urine satured bed linens. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 08/20/2024 and ended on 08/21/2024 The facility corrected the noncompliance before the investigation began. This deficient practice could result in residents not receiving the necessary care to maintain optimum health and place them at risk of skin breakdown. Findings included: Record review of Resident #1's clinical record revealed a 69 -year-old male admitted to the facility originally on 08/04/22 with diagnoses to include MULTIPLE SCLEROSIS, ANXIETY DISORDER, UNSPECIFIED, BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS, VOLVULUS, IMMOBILITY SYNDROME (PARAPLEGIC), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE, MUSCLE WEAKNESS (GENERALIZED), OTHER MALAISE, NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED, VITAMIN D DEFICIENCY, UNSPECIFIED, CHRONIC IDIOPATHIC CONSTIPATION. , HEMIPLEGIA, UNSPECIFIED AFFECTING RIGHT DOMINANT SIDE, CHRONIC PAIN SYNDROME, MODERATE PROTEINCALORIE MALNUTRITION, CONTRACTURE, RIGHT WRIST, DEPRESSION, UNSPECIFIED, and PARAPLEGIA, UNSPECIFIED. Record review of Resident #1's clinical record revealed a 14-day MDS completed on 08/04/24 with a BIMS score of 13 indicating he was cognitively intact and a functional status of requiring two-person assistance with all activities. Section H-Bladder and Bowel H0100 A. Indwelling Catheter-Resident #1 was marked yes. Page 1 of 3 676157 676157 09/13/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0684 Record review of Resident #1's clinical record revealed a care plan with the following: Level of Harm - Minimal harm or potential for actual harm Problem: I am incontinent of bowel and r/t Multiple Sclerosis with loss of peritoneal tone and muscle control. I will remain free from skin breakdown due to incontinence. breakdown, if I am not cleaned properly and regularly. Related To: MS. Check me during rounds and as required for incontinence. Provide peri care with each incontinent episode. Change clothing PRN after incontinent episode. Revised on 9/03/24 observe skin while providing peri care and report signs of breakdown to the Nurse. Residents Affected - Few Record review of Resident #1's clinical record revealed Active Orders with start dates from 5/21/24, 6/29/24. There were orders for catheter care, monitoring, or maintenance. Suprapubic Catheter 24Fr 10cc, change monthly and PRN every 1 hours as needed. Record review of Resident #1's Progress Note on 09/13/24 at 9:22 am revealed his foley was leaking around the insertion site. The foley was changed using sterile technique. During an observation on 09/12/24 at 9:19 AM, Resident #1 was in bed sleeping. A urinary catheter was noted hanging from the side of Resident #1's bed in a privacy bag. Observations and Interviews revealed sampled resident were clean and dry. During an observation on 09/13/24 am, Resident #1 was lying in bed watching TV. CNA G checked resident #1s catheter to ensure it was not leaking. During an interview on 09/12/24 at 11:43 AM, the DON stated a resident with a catheter should have orders for the catheter. Yes, they should have an order for a catheter and the care. The DON said the alleged CNA L on 08/20/2024 did not check Resident #1 during her rounds that morning. Resident 1 was found with a saturated brief and bed linens. The DON said the CNA L was terminated. During an interview on 09/12/24 at 3:30 pm, ADM stated CNA L did not do her job on 8/20/24 and was suspended due to pending investigation and then was terminated on 8/30/2024. During an interview on 09/12/24 at 9:23 am, RN B she said she completed a full skin assessment Resident #1 on 8/20/2024 after the CNAs finished cleaning him up. RN B stated the skin assessment did not reveal any skin breakdown and that Resident #1's skin was clear. RN B stated that there were multiple areas of blanchable redness with no skin breakdown. During an interview on 9/13/24 at 9:51 am, CNA I stated that when she was passing meal trays on 8/21/24 around 11:30 am, she found Resident #1 soaking in urine in his bed. CNA I stated she reported the incident to the nurse. CNA I stated the nurse assessed the resident after they cleaned him up. Record review of the facility's Provider Investigation Report revealed the following. The Provider Investigation Report was completed and signed on 8/26/24. The facility's investigation revealed that CNA L failed to check on Resident #1 in the morning of 8/20/24, resulting in Resident #1 being left unattended for an extended period of time. When assessed by RN B, Resident #1 was noted to have a large urine stain under him on the bottom sheet. RN B assessed Resident #1's suprapubic catheter and found it to be leaking. A skin assessment performed by RN B noted multiple areas of blanchable redness, no open areas. The Provider Investigation Report further documented that CNA L was immediately suspended pending the outcome of the investigation. The Provider Investigation Report documented this interview with CNA L by Admin: 8/20/24 2:15pm {Admin} met with {CNA L} related to an alleged 676157 Page 2 of 3 676157 09/13/2024 Ussery Roan Texas State Veterans Home 1020 Tascosa Rd Amarillo, TX 79124

F 0684 Level of Harm - Minimal harm or potential for actual harm abuse/neglect allegation .{Adm} asked {CNA L} if she had checked on Resident #1 this morning. {CNA L} replied that she did not go into Resident #1's room as she got busy Record review of Resident #1's nursing progress notes dated 8/20/24 at 12:44pm by RN B revealed, This nurse assessed resident head to toe after report of not being changed . Residents Affected - Few Record review of facility provided in-service titled Resident Rights-Abuse/Neglect, Rounding, Catheter Care conducted on 8/21/24 revealed the facility's abuse/neglect policies were reviewed. Record review of the facility provided policy titled, Resident Rights undated, revealed the following: Right of the Elderly. b. An elderly individual has the right to be treated with dignity and respect . 2. has the right to be free from abuse, neglect . 676157 Page 3 of 3