Health inspection·July 23, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 of 3 residents (Resident #1) reviewed for quality of care. Residents Affected - Few The facility failed to follow physician's orders and the comprehensive care plan to monitor Resident #1 for edema. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: Review of Resident #1's quarterly MDS assessment, dated 06/19/24, Section A (Identification Information) reflected a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Section I (Active Diagnoses) reflected diagnoses including heart failure (heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure), anemia (lack of red blood cells in the blood), renal insufficiency (impaired kidney function), diabetes (a condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), and chronic respiratory failure with hypoxia (not enough oxygen in the blood). Section C (Cognitive Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section N (Medications) reflected Resident #1 took diuretic medication (medicines that increase urine production and help lower blood pressure and fluid retention). Review of Resident #1's comprehensive care plan, initiated 06/05/24, reflected a Focus: The resident has Congestive Heart Failure. The Goal reflected: The resident will have clear lung sounds, heart rate, and rhythm within normal limits through the review date. Interventions included: Give cardiac medications as ordered. Monitor/document/report to MD PRN any s/sx of congestive heart failure: dependent edema of legs and feet, periorbital edema (edema around the eyes), shortness of breath upon exertion, cool skin . Review of Resident #1's Order Summary, reflected a physician's order dated 07/01/24, Monitor edema every shift. Review of Resident #1's medication administration record and treatment administration record, both for July 2024, reflected no monitoring of edema each shift as ordered by the physician. During an interview on 07/23/24 at 1:35 PM, the REGN stated, she would expect to see edema Page 1 of 2 676227 676227 07/23/2024 Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

F 0684 Level of Harm - Minimal harm or potential for actual harm monitoring on the treatment administration record since the doctor had ordered edema to be monitored each shift. After review of the order, she stated the order was not correctly entered into the computer system so the order was not reflected on the treatment administration record. She stated the DON and ADON were responsible for monitoring the physician's orders. She stated if staff did not monitor edema, they would not have known if the resident had a change in her edema. Residents Affected - Few During an interview on 07/23/24 at 1:55 PM, the DON stated the charge nurse was usually responsible for entering and initiating physician orders when received from the provider. She stated the order to monitor edema each shift should have been on the treatment administration record. She stated not monitoring edema could lead to an increase in symptoms or change in condition that was not noticed timely. She stated the ADON usually monitored the new orders. During an interview on 07/23/24 at 2:01 PM, the ADM stated physician orders needed to be accurately transcribed when entered in the computer. She stated she was not a clinical person but knew the physician's orders should have been followed. She stated the DON was responsible for monitoring the physician's orders. Review of a document from the Medical Records Manual 2015, titled Physician Orders, reflected in part, Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident . Verbal or Telephone Orders by the physician or nurse practitioner 3. The nurse will enter the order into the Electronic Medical Record for the resident and select either verbal or telephone, depending on how the nurse received the order. 4. If the order requires documentation, it will be directed to the proper electronic administration once the order is completed . 676227 Page 2 of 2