Health inspection·November 7, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 5 residents reviewed for clinical records. The facility failed to ensure staff documented need for Resident #1 to receive oxygen treatment. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records. Findings included: Review of Resident #1's undated electronic face sheet a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of hypokalemia (a lower-than-normal potassium level in your bloodstream), Hypernatremia (common electrolyte problem), hyperosmolality (loss of water also makes the blood more concentrated than normal), dementia without behavior disturbance, dysphagia (swallowing difficulties) Review of Resident #1's admission MDS Assessment, dated 10/18/23, reflected a BIMS score was not completed. The MDS did not indicate that oxygen was required for Resident #1. Review of the care plan completed 10/18/23 revealed the resident required assistance with act of daily living. The care plan did not indicate that oxygen was required for Resident #1 Review of Resident#1' nursing note dated 10/29/23 at 7:42PM authored by RN #1 revealed Resident #1's oxygen level was at 95% and resident on 3 liters of oxygen via nose cannula. There was no documentation of Resident#1's oxygen being low, nor the physician or family being notified of the resident receiving oxygen. Review of the electronic physician orders dated 11/07/23 revealed no order for oxygen. Review of the standing orders revealed oxygen per nose cannula to keep oxygen stats above 92 percent. Interview on 11/07/2023 at 1:45PM with RN #1 revealed he had worked in the facility for 4 years. He stated upon checking the oxygen levels for Resident #1 her oxygen was low. RN#1 stated he did not document the low oxygen level and only documented the oxygen level at 96%. RN #1 revealed there was a Page 1 of 2 676243 676243 11/07/2023 Remington Transitional Care of Richardson 1350 E Lookout Dr Richardson, TX 75082

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few standing order which stated if the resident oxygen were below 92% then oxygen should have been given. RN#1 stated he was not sure how long Resident#1 was on oxygen due to his shift ending. RN#1 stated he did not notify the doctor nor family regarding oxygen being given. RN#1 stated he forgot to document the low oxygen level. Review of Resident #1's nursing notes dated 10/30/23 at 7:19 AM author by RN#2 revealed Resident #2 was met with oxygen at 3 liters via nose cannula. RN#2 noted Resident #1's oxygen saturation dipping when not on oxygen. RN#2 recorded Resident#1's oxygen status at 78%. RN #2 did not document that the physician was notified, nor an order given to continue oxygen . Review of Resident #1's nursing notes dated 10/30/23 at 3:43PM authored by the infectious disease doctor, revealed hypoxia on room air and Resident #1 on 2 liters of oxygen via nose cannula. There was no documentation of an order give for continued use of oxygen. Interview on 11/07/23 at 2:15PM with RN#2 revealed during rounds she noted that Resident#1 was receiving 3 liters of oxygen. She stated she attempted to remove the oxygen and Resident#1's oxygen saturation dropped to 78%. RN #2 stated she provided 3 liters of oxygen via nose cannula. RN#2 stated she contacted the physician and as given a verbal order to continue oxygen and a x ray was order. RN#2 stated she thought she documented the contact that was made with the physician. Interview on 11/07/23 at 3:00PM with the DON revealed there was a standing order for oxygen levels below 92%. The DON she did not think there was a need to get an order to continue oxygen due to the standing order being in place. The DON stated she did not think there was a risk to residents due not obtaining the order or contacting the physician due to the current standing order. Review of the facility policy Documentation of medical record dated 06/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. 676243 Page 2 of 2