Health inspection·October 26, 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 observation, interview and record review, the facility failed to maintain and accurately document medical records on 1 (Resident #1) of 3 residents housed in the secure unit of the facility. The facility obtained a physician's order but failed to put the order in Resident #1's chart. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, and inaccurate medical records. Findings Included: Record review of Resident #1's face sheet, dated 10/26/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included but are not limited to unspecified dementia, major depressive disorder, blindness in left eye, and polyneuropathy (damage or disease affecting peripheral nerves). Record review of Resident #1's MDS, dated [DATE], indicated a BIMS score of 05 indicating severe cognitive impairment. Resident #1 MDS, section E-Behavior revealed no prior behaviors. Record review of Resident #1's care plan, dated 9/13/23 with a revision on 10/23/23, revealed a focus of resident resides in the Secure Care Unit, related to diagnosis of dementia and risk for elopement. Interventions/Tasks indicated: Admit to Secure Care unit per MD orders. Record review of Resident #1's physician orders, dated 10/11/23, revealed no physician order for admit into the secure unit. Record review of Resident #1's progress notes, dated 10/21/23, unknown author, that Resident #1 was attempting to leave the facility. Per DON, the resident was to be moved to room [ROOM NUMBER]. Observation and interview on 10/26/23 at 10:56 AM revealed room [ROOM NUMBER] was in the locked unit on hall 2. Observed Resident #1 lying in bed with strong urine odor. Resident was unable to recall incident. When asked if someone pinched another resident, Resident #1 stated, I would more than likely hit them or slap them. I don't pinch. Observed Resident is oriented to person. Resident #1 did have an instance of asking for surveyor's name again. An interview on 10/26/23 at 2:39 PM with DON revealed the resident was an elopement risk and she had attempted to elope two times. DON stated when the on-call provider was notified, the provider Page 1 of 2 676341 676341 10/26/2023 Caprock Nursing & Rehabilitation 900 College Ave Borger, TX 79007

F 0842 indicated to put the resident on the locked unit and provided an order. Level of Harm - Minimal harm or potential for actual harm An interview on 10/26/23 at 3:10 PM with ADON A revealed the procedure for being placed on the locked unit was they must have an order by a physician. ADON A and ADON B attempted to locate order and an order was not present in the resident's records. Residents Affected - Few An interview on 10/26/23 at 3:35 PM with ADM revealed residents must have a physician's order to be admitted to the locked unit. An interview on 10/26/23 at 4:01 PM with ADON B revealed a negative outcome for a resident not having an orders would be the employee would need coaching for not placing the order in the resident's chart and it does not provide the care they need. Record review of policy SecureCare Environment admission Criteria and Process, revised February 1, 2007, states under Policy, Line 2- The need for admission to the SecureCare Environment must have a physician's order. 676341 Page 2 of 2