Health inspection·October 17, 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 that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 8 residents reviewed for care plans. -The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3's use of a BiPAP machine. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs. Findings include: Review of Resident #3's admission Record dated 10/15/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3's diagnoses included acute and chronic respiratory failure with hypoxia (medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide leading to deficiency of oxygen in blood which can occur suddenly or develop over time due to various underlying lung diseases or conditions), chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and dependence of supplemental oxygen. Review of Resident #3's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 indicating the person as intact cognitively. Section O - Special Treatments, Procedures, and Programs revealed Resident #3 on continuous oxygen therapy. Review of Resident #3's Order Summary Report dated 10/16/2024, revealed an order with start date of 09/09/2024 for BIPAP S/T at night, bleed in O2 keep saturations above 90% via full face mask every night shift 10 p.m. to 6 a.m. Review of Resident #3's care plan dated 10/16/2024, revealed a focus area of oxygen therapy. Interventions did not include any information regarding the use of a BiPAP. The use of the BiPAP was not care planned. Review of Resident #3's TAR for September 2024, revealed nighttime use of the BiPAP was followed Page 1 of 2 676342 676342 10/17/2024 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0656 according to physician orders from 09/09 to 09/20/2024. Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's Oxygen Saturations from 09/09/2024 to 09/20/2024 revealed resident's saturations were checked multiple times a day and remained above 90%, with average being 95.3%. Residents Affected - Few During an interview on 10/17/2024 at 10:54 a.m., the DON said Resident #3 using the BiPAP should have been care planned. The DON said the orders for Resident #3's use of the BiPAP were followed and documented. The DON said it was the nursing and MDS nurses' responsibility to make sure care plans are updated and accurate. The DON said specifically it was her and the ADONs responsibility to make sure that the BiPAP was care planned and it was not. The DON said she did not know why the care plan was not updated to include the BiPAP use. The DON said there was a risk of not following the resident's plan of care to meet the patient's needs. During an interview on 10/17/2024 at 11:06 a.m., MDS CM said she reviewed Resident #3's care plan and noted that the use of the BiPAP was not care planned. The MDS CM said the use of the BiPAP should have been care planned. The MDS CM said the resident had been re-admitted to the facility in July and was treated like a new admission regarding assessments. The MDS CM said when Resident #3 was re-admitted she was still on a tracheostomy status and a ventilator. The MDS CM said their policy was MDS nurse does care plan reviews when they complete an initial MDS assessment, and during quarterly look backs. The MDS CM said the BiPAP was not included in the look back period during the July review. The MDS CM said the floor staff nurses or ADONs should have care planned the changes. During an interview on 10/17/2024 at 11:30 a.m., the Administrator said it was the responsibility of MDS nurse and nursing to make sure care plans are updated. The Administrator said with the issue regarding Resident #3's use of the BiPAP, the nursing staff should have care planned the use. The Administrator said he reviewed all documents related to care of the patient and found that patient orders were in place and the resident received the services, but it was not care planned. The Administrator said the purpose of a care plan was for direct care staff to be aware of the plan to treat or care for the needs of a resident. The Administrator said there was a risk of treatment not being provided to residents if the care plan is not accurate. Review of facility-provided Comprehensive Care Planning policy undated, reads in part Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Care planning drives the type of care and services that a resident receives. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. 676342 Page 2 of 2