Health inspection·July 24, 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 consult with the resident's physician and when there is a need to alter treatment significantly for 1 out of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify and consult with the physician about the changes in Resident #1's wounds on his left lower extremity. This failure could place residents at the risk of not receiving appropriate medical interventions, which could result in severe illness or hospitalization. Findings include: A record review of Resident #1's electronic Face Sheet, dated 07/19/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with unspecified complications, pressure ulcer of right buttock stage 4, pressure ulcer of sacral region stage 4, partial amputation of right foot, hypo-osmolality and hyponatremia (occurs when the concentration of sodium in your blood is abnormally low), acute osteomyelitis right foot and ankle (a serious infection of the bone), and other skin changes. A record review of the Resident #1's MDS, dated [DATE], reflected a BIMS of 99, which indicated the resident was unable to complete the interview. The MDS reflected Resident #1 had 3 Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough [dead tissue, usually cream or yellow in color] or eschar [a dry, dark scab or falling away of dead skin] may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcers at the time of admission. Further review reflected Resident #1 had open lesion(s), other than ulcers, rashes, cuts. Resident #1 required extensive physical assistance of two or more staff for bed mobility. Resident #1 was total dependence by two or more staff for transfers, dressing, toilet use, and personal hygiene. A record review of Resident #1's Care Plan, dated 06/26/23, reflected a care area for skin breakdown related to: wounds on left foot, right buttock, left buttock, and sacrum; skin tear wound left forearm, history of bruises/skin tears; history of pressure injury; history of stroke, and history of cardiovascular disease. The interventions included: assist resident to turn and reposition frequently; condition of each area of skin breakdown to be documented with every treatment and/or dressing change; inspect skin complete body head to toe every week and document results; inspect skin daily with care and bathing, and report any changes to charge nurse; notify physician of any worsening of skin Page 1 of 4 676192 676192 07/24/2023 Garnet Hill Rehabilitation and Skilled Care 1420 McCreary Rd Wylie, TX 75098

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few breakdown; treatments and dressings as ordered per physician; and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. A record review of Resident #1's nurses notes did not reflect any documentation regarding a change in condition of the wound on resident's lower left extremity, the wound having access drainage, or the wound draining and required a bandage. A record review of Resident #1's nurses notes, dated 07/17/23, written by RN A, reflected 4.00 resident is alert, refused breakfast, lunch and dinner. Resident kept yelling. Comfort care rendered, denies any pain. VS (vitals): 109/67, 98, 22, 98, 2.62. At 4:55, nurse received call from [family member] and requested that pt (patient) be transferred to [hospital]. Hospice called and gave order to transfer pt as required by family. [NP] is notified . Nurse called [Transport] [Transport's phone number]. Endorsed to in-coming nurse. A record review of Resident #1's TAR, dated July 2023, did not reflect any documentation of abrasions, skin tear, or wound to Resident #1's left lower extremity. The TAR reflected resident #1 had various other wounds and had received wound care by RN B on 07/16/23. A record review of the EMS Transport Report, dated 07/17/23, reflected EMS noted bandage on left knee which had been saturated and soaked through with yellow drainage. Bandage had the date: 7/16/2023 on it. Under the bandage, there were three abrasions with white puss. Knee was visibly swollen. A record review of Resident #1's admitting hospital records, dated 07/17/23, reflected Pt has left leg swelling and redness. He has chronic wound and drainage noted on L (left) knee. Musculoskeletal: Left Lower Leg: Swelling present. Comments: Patient has discharge on his left knee. Diagnosis: [R41.01] Delirium [S81.802A] Wound of left lower extremity, initial encounter. The hospital Wound Care Initial Consult reflected Wound Description: various abrasions; Location: left leg; Size: 2 cm x 2cm 0.1 cm; Wound Base: pink moist with yellow slough (necrotic tissue that needs to be removed from the wound for healing to take place); Exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation): scant yellow slough. In an interview on 07/19/23 at 2:34 PM, RN A stated on 07/17/23 Resident #1 was not acting like his normal self. RN A stated he was agitated but he was not complaining of pain. She stated the CNAs reported he did not eat his breakfast, and she noticed his hands were swollen, but he had chronic edema. RN A stated she assessed him, and his vitals were normal, but he seemed uncomfortable. RN A stated she notified the family and contacted his hospice nurse, who came and assessed Resident #1 around lunch time. She stated the hospice nurse contacted the physician and she was provided new orders for his medication. RN A stated she put in the new order, but it would not take effect until 07/18/23. She stated she was doing rounds like every 1-2 hrs. to check vitals. RN A stated his vitals remained normal. RN A stated he had skin tears all over his body, but she did not notice any excessive draining. She stated she could not recall if there was a dressing on his left leg/knee area. She stated the wound care nurse handles his wound care daily. RN A stated later in the evening she received a call from his family, who stated they had declined hospice and requested he be sent out to the hospital. She stated she verified with hospice, notified the MD and DON, and contacted the transport company. In an interview on 07/20/23 at 2:39 PM, RN B stated he did provide wound care to Resident #1 on 07/16/23. He stated he had wounds on his sacrum, buttocks, left foot, and his arm, which he believed 676192 Page 2 of 4 676192 07/24/2023 Garnet Hill Rehabilitation and Skilled Care 1420 McCreary Rd Wylie, TX 75098

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was the right arm. RN B stated he has skin tears and abrasions all over his body at various stages of healing. He stated some are almost healed, some had scabs, and some are opened. RN B stated Resident #1 would scratch and pick at his skin, which caused skin tears and abrasions. He stated the open wounds would drain. RN B stated if he noticed Resident #1 was picking at the wounds, then he would wrap his arms and legs to avoid him picking at the wounds, which could cause them to get infected. He initially stated he did not recall seeing any wounds on John's left leg or knee. When RN B was asked why would it be reported that there was a dressing dated 07/16/23 on his left knee area, which was reported to have yellow drainage and white pus, he stated he did recall cleaning and putting a dressing in that area. He stated the knee area had skin tears and they were draining a lot, so he cleaned it and put on a dressing. RN B stated he could not recall what the drainage looked like. He stated when this happened, he was supposed to notify the wound doctor and wait for any new orders. RN B stated he did not notify the wound care doctor because he was busy and forgot. He stated he had other residents to provide wound care for. In an interview on 07/24/23 at 11:11 PM, RN C stated she was a PRN wound care nurse. She stated on Monday 07/17/23 she was told Resident #1 was sent to the hospital at his family's request. RN C stated she had provided wound care to Resident #1 on Friday 07/14/23 with the Wound Doctor (WD). She stated they did wound care to the wounds on Resident #1's bottom, left toe, and his arm. RN C stated Resident #1 had small skin tears all over his body because he picked at his skin. She stated she did recall seeing skin tears on his left knee and around the knee area. RN C stated she did not recall seeing the skin tears draining. She stated if wounds, including skin tears or abrasions, had new yellow drainage or white pus, they were supposed to notify the Wound Doctor and the DON and wait for orders. In an interview on 07/24/23 at 12:06 PM, the DON stated wounds, skin tears, and abrasions should be documented and reported to the wound nurse and wound doctor. She stated changes in the wounds, such as yellow drainage or white pus, should be reported to the wound nurse and wound doctor. She stated yellow drainage or white pus, redness, and inflammation are signs of infection, so should be reported to the wound doctor and her. The DON stated Resident #1 had multiple abrasions on his body due to him picking and scratching at his skin. She stated RN B never notified her of any changes to Resident #1's wounds or abrasions. In an interview on 07/24/23 at 3:09 PM, the WD stated a change in condition for wounds included deterioration, swelling, and increase in serious drainage. He stated open wounds drain which is a sign of healing, but he is concerned when it is excessive drainage or purulent drainage (a white, yellow, or brown fluid and might be slightly thick in texture) or white pus. The WD stated Resident #1 was non-complaint with his care and often picked at his skin, which caused abrasions. He stated Resident #1 had open wounds all over his body, which always drained. The WD stated he did not treat skin tears or abrasions and those were handled by the wound nurse. He stated they had standard orders for caring for skin tears and abrasions. The WD stated if the skin tear or abrasion had excessive draining, purulent drainage or pus, then he should be notified. The WD stated he last saw Resident #1 on Friday 07/14/23, and he did not see any of the skin tears or abrasions opened with excessive draining, purulent drainage, or white pus. He stated he was not notified on 07/16/23 that Resident #1's abrasions on his left lower extremity had yellow drainage or pus. The WD stated, if he was notified of this hew would have provided orders for an antibiotic because that was signs of infections and Resident #1 had a history of infection. A record review of the facility's policy titled Change of Condition, dated 02/13/23, reflected Changes in condition of the patient are determined by current and past medical conditions, medical 676192 Page 3 of 4 676192 07/24/2023 Garnet Hill Rehabilitation and Skilled Care 1420 McCreary Rd Wylie, TX 75098

F 0580 Level of Harm - Minimal harm or potential for actual harm orders, patient safety factors and/or by assessments utilizing defined parameters as outlined by the INTERACT 4.5 Change in Condition . Categories are listed as: . 3. Signs and Symptom . Notification categorized as: Immediate Notification: Any symptoms, sign or apparent discomfort that is Acute or sudden in onset, and: A marked change (i.e. more severe) in relation to usually symptoms and signs or Unrelieved by measures already prescribed. Residents Affected - Few A record review of the facility's policy titled NON- Pressure Wounds: Skin Tears and Lacerations, dated July 2018, reflected Procedure: . 2. Follow standard precautions and infection control methods depending on the appropriate type of transmission based precautions. 7. In the event of a change in the wound, the physician is to be notified. 676192 Page 4 of 4