Health inspection·July 12, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and records review, the facility failed to ensure that medical records were accurately documented for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for accurate clinical records, in that: The facility failed to ensure Resident #1, Resident #2, and Resident #3's weekly skin evaluations, weekly pressure/non-pressure ulcer evaluations, care plans, and MDS' were completed and accurately described their current skin integrity issues. This deficient practice could result in errors in care and treatment. Findings included: Review of Resident #1's undated face sheet reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including epilepsy (seizures), personal history of traumatic brain injury, unspecified dementia, and history of falling. Review of Resident #1's quarterly MDS assessment, dated 06/19/23, reflected his BIMS had not been completed. Section M (Skin Conditions) reflected he had MASD. Review of Resident #1's quarterly care plan, revised 07/01/23, reflected he had an alteration in skin integrity related to the presence of a skin tear on his left elbow with an intervention to assess and document the status of skin tear weekly and as needed. Review of Resident #1's physician order, dated 06/17/23, reflected a skin tear to his left forearm cleanse with NS or wound cleanser, pat dry, apply xeroform, cover with dry foam dressing. Monitor for signs and symptoms of infection. Review of Resident #1's physician order, dated 06/26/23, reflected to cleanse left elbow with NS, pat dry, approximate edges, apply steri strips and to monitor area QD for ss of infection until healed. Review of Resident #1's weekly skin evaluation, dated 06/23/23, reflected he had non-pressure wounds: Skin tear to left elbow x2, 4cm linear in shape, 2cm linear in shape. The name of the nurse who completed the evaluation was not documented. Review of Resident #1's weekly skin evaluation, dated 06/26/23, reflected he had non-pressure Page 1 of 4 676180 676180 07/12/2023 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some wounds: skin tear(s) to left forearm, left elbow, and right arm. The name of the nurse who completed the evaluation was not documented. Review of Resident #1's weekly non-pressure ulcer evaluation, dated 06/26/23, reflected he had a left elbow skin tear. There were no documented measurements. The name of the nurse who completed the evaluation was not documented. Review of Resident #1's weekly skin evaluation, dated 07/03/23, reflected he had a non-pressure wound with no details of what the wound was or where it was located. The name of the nurse who completed the evaluation was not documented. Review of Resident #1's weekly non-pressure ulcer evaluation, dated 07/03/23, reflected no documentation of any wounds or skin integrity issues. The name of the nurse who completed the evaluation was not documented. Review of Resident #1's EMR, on 07/12/23, reflected no evaluations had been conducted after 07/03/23. Review of Resident #2's undated care plan reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a chronic degenerative disorder of the central nervous system that mainly affects the motor system), epileptic seizures, muscle wasting and atrophy (wasting away), and history of falls. Review of Resident #2's quarterly MDS assessment, dated 04/24/23, reflected a BIMS of 9, indicating a moderate cognitive impairment. Section M (Skin Conditions) reflected he had no skin integrity issues. Review of Resident #2's quarterly care plan, revised 05/03/23, reflected he was at risk for impaired skin integrity related to impaired mobility with an intervention of conducting skin inspections/examinations weekly and as needed and to document findings. Review of Resident #2's weekly skin evaluation, dated 06/20/23, reflected he had a pressure ulcer and treatment orders for his left heel. The name of the nurse who completed the evaluation was not documented. Review of Resident #2's weekly pressure ulcer evaluation, dated 06/20/23, reflected he had pressure injury to his left heel. There was no documentation of the measurements of the injury or the stage. The name of the nurse who completed the evaluation was not documented. Review of Resident #2's weekly skin evaluation, dated 06/27/23, reflected he had no new skin issues. The name of the nurse who completed the evaluation was not documented. Review of Resident #2's weekly skin evaluation, dated 07/04/23, reflected he had no new skin issues. The name of the nurse who completed the evaluation was not documented. Review of Resident #2's weekly skin evaluation, dated 07/11/23, reflected he had no new skin issues. The name of the nurse who completed the evaluation was not documented. Review of Resident #2's EMR, on 07/12/23, reflected a weekly pressure evaluation had not been 676180 Page 2 of 4 676180 07/12/2023 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621

F 0842 conducted since 06/20/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II diabetes, muscle wasting and atrophy, wedge compression fracture of T11-T12 vertebra (a bone of the spine), and hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) and affection his right dominant side. Residents Affected - Some Review of Resident #3's admission MDS assessment, dated 06/16/23, reflected a BIMS of 3, indicating a severe cognitive impairment. Section M (Skin Conditions) reflected he had no skin integrity issues. Review of Resident #3's initial baseline care plan, revised 07/05/23, reflected he had a suspected DTI (detected on 06/30/23) to right lateral foot and hell and potential for further pressure ulcer development related to immobility with an intervention of assessing/recording/monitoring wound healing, measuring the length, width, and depth and assessing and documenting status of wound perimeter, wound bed, and healing progress. Review of Resident #3's physician order, dated 06/30/23, reflected a suspected DTI to right lateral foot and heel - clean with NS, pat dry wit gauze, and apply betadine, leave OTA. Review of Resident #3's weekly skin evaluation, dated 07/08/23, reflected he had no abnormal skin issues. The name of the nurse who completed the evaluation was not documented. Review of Resident #3's EMR, on 07/12/23, reflected no weekly skin evaluations or weekly non-pressure ulcer evaluations had been conducted since 07/08/23. No weekly non-pressure ulcer evaluations had been conducted since the detection of the DTI on 06/30/23. During an observation and interview on 07/12/23 at 11:02 AM, reflected the DON assessing Resident #3's right foot. There was a dime-size light pink area on the bottom of his heel. Resident #3 denied any pain to the area when asked. During an interview on 07/12/23 at 11:17 AM, the DON stated nurses were responsible for conducting thorough weekly skin assessments on their residents. She stated if the resident had a skin integrity issue, a pressure/non-pressure assessment should be conducted weekly. She stated both assessments should describe what they see, such as measurements and the stage of the wound. She stated if the assessments were not being conducted accurately, there would be potential that they could be missing a whole lot of skin issues which could lead to hospitalization or death. During an interview on 07/12/23 at 1:12 PM, the ADM stated it was extremely important for all skin assessments to be conducted timely and accurately by the nurses. He stated the DON was ultimately responsible in ensuring the accuracy of the assessments. He stated the skin assessments were part of the whole skin system as they addressed multiple facets to ensure something did not get missed. He stated that details of the assessments counted, such as measurements of the wounds/injury. He stated they assisted in tracking the progress of the wound, and let the staff know if they needed to change interventions or if it was something they needed to discuss in their QAPI meetings. He stated the residents' care plan and MDS should mirror the skin assessments, and that was the nurses' responsibility as well. He stated if the assessments were not done accurately with all the details addressed, there was potential for negative outcomes such as the possibility for the wounds/injuries worsening. 676180 Page 3 of 4 676180 07/12/2023 Elgin Nursing and Rehabilitation Center 1373 North Avenue C Elgin, TX 78621

F 0842 Review of the facility's Skin Assessment policy, implemented 12/07/22, reflected the following: Level of Harm - Minimal harm or potential for actual harm Policy Explanation and Compliance Guidelines: Residents Affected - Some 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon administration/re-admission, weekly for three weeks, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. . 7. Documentation of skin assessment: a. Include date and time of the assessment. b. Document observations (e.g., skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of issue in wound bed, drainage, odor, pain). Review of the facility's Documentation in Medical Records policy, implemented 10/24/22, reflected the following: 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. 676180 Page 4 of 4