Health inspection·August 21, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #15) reviewed for care plans. The facility failed to ensure Resident #15's care plan reflected diagnoses of infections and the physician's orders for antibiotic therapy. This failure could place residents at risk of not receiving care and services to meet medical and nursing needs. The findings included: Record review of a face sheet dated 08/20/24 indicated Resident #15 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of subdural hemorrhage (bleeding between the brain and the skull), dementia, diabetes mellitus, and MSSA (methicillin-sensitive-staphylococcus aureus) bacteremia (an infection caused by MSSA entering the bloodstream). Diagnoses of urinary tract infection, pneumonia, and obstructive and reflux uropathy (disorder of the urinary tract that obstructs urine flow) were added to the diagnosis list on 01/24/2024. Record review of an MDS quarterly assessment dated [DATE] indicated Resident #15 had a BIMS score of 7 (severely impaired cognition), was incontinent of bowel and bladder, and required substantial to maximum assistance with bathing and hygiene care. Record review of Resident #15's MDS (Section I: Active Diagnoses) dated 04/05/2024 indicated Resident #15 had diagnoses of pneumonia and a urinary tract infection. Record review of Resident #15's MDS (Section N :High Risk Drug Classes) dated 07/06/2024 indicated Resident #15 was receiving an antibiotic with an indication for use. Record review of laboratory results of urine testing on 02/27/2024, 03/29/2024, and 04/26/2024 indicated Resident #15 tested positive for urinary tract infections on all 3 (three) dates. Record review of Resident #15's physician orders since admission indicated Resident #15 had orders dated 02/27/2024 for the antibiotic Macrobid, 02/28/2024 for the antibiotic Cipro, and 03/30/2024 for the antibiotic Omnicef to treat urinary tract infections. An order dated 05/02/2024 indicated Resident #15 was to receive Keflex (an antibiotic) 3 (three) days a week for prophylactic treatment of Page 1 of 2 676286 676286 08/21/2024 Meadow Lake Health Center 16044 County Road 165 Tyler, TX 75703

F 0656 urinary tract infections on an ongoing basis. Level of Harm - Minimal harm or potential for actual harm Record review of a Medication Administration Record dated August, 2024 indicated Resident #15 was receiving Keflex 3 (three) days a week on Monday, Wednesday, and Friday. Residents Affected - Few Record review of Resident #15's Care Plan dated 08/20/24 indicated the comprehensive care plan was initiated on 01/31/2024 and had not been updated to include actions/interventions to address Resident #15's diagnoses of pneumonia and urinary tract infections nor antibiotic usage since admission. The care plan did not include any concerns nor interventions to address Resident #15's risk for urinary tract infection, actual urinary tract infections, nor past or current use of ongoing prophylactic use of an antibiotic. During an interview with the DON at 03:30 PM on 08/20/2024, he said care plans were completed on admission and updated at least quarterly and as needed. He said Resident #15's care plan should have addressed each of the infections she had incurred and should have been updated to address Resident #15's current antibiotic therapy. The DON said the failure to address these issues in the care plan was an oversight. The DON said the care plans were individualized to each resident and it was important to keep the care plans updated and accurate to ensure a resident's needs and interventions to meet those needs were communicated. He said everyone on the interdisciplinary care plan team was responsible for ensuring care plans were complete. A review of the facility's policy titled Comprehensive Care Plan indicated the following: Procedures 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, g. Incorporate identified problem areas, h. Incorporate risk factors associated with identified problems, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 676286 Page 2 of 2