Health inspection·June 2, 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 ensure medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 4 residents (Resident #1) reviewed for accuracy of medical records, in that: Resident #1's Weekly Skin and Wound Evaluation was not completed for Resident #1 from 5/4/23 to 6/2/23. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #1's face sheet, dated 5/25/23, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: type 2 diabetes mellitus, kidney disease, sepsis, and defibrinating syndrome (Condition affecting the blood's ability to clot and stop bleeding). Record review of Weekly Skin and Wound Evaluation dated 5/3/23 indicated: Resident #1 had 3 wounds that were POA from Hospital. Wound #1 Surgical wound, Right Below Knee Amputation BKA wound measuring 13x15x0.3. Wound #2 Surgical wound, Right arm measuring 30x30x0.2. Wound #3 Surgical Wound, left pinky measuring 4x0.2x0. Record review of Resident #1's MAR dated 5/26/23 indicated that wound care was not missed from 5/3/23 to 5/26/23. MAR indicated DON, charge nurse, or night nurse performed wound care. During an interview on 5/26/23 at 11:15 AM WCN-A stated she was out of the facility from 5/5/23 to 5/27/23. She stated that when she first saw the resident and did the initial assessment on 5/3/23 the right arm from elbow down was black. She stated there was a wound down between the index and middle finger, on the right hand. She stated the other wound was up on the forearm 2 inches below the elbow. She stated when she assessed the arm on 5/28/23 the entire arm from elbow down was still black. She stated that two wounds looked to be improving but had drainage. She stated near the wrist it looked as if the necrotic tissue had fallen off and red skin was underneath. She stated she cleaned it and it looked to be healthy skin. She stated it did have some drainage that she cleaned up. She stated overall there was not a huge difference from initial to the last day she saw him in the improvement of his skin. She stated I don't know why the Weekly Skin and Wound assessment was not complete for pretty much the entire month of May. She stated that when she is not at the facility, wound care Page 1 of 2 676348 676348 06/02/2023 Madison Medical Resort 5001 Office Park Drive Odessa, TX 79762

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few is to be done by the DON, ADON, or charge nurse and the Weekly Skin and Wound assessment should be done by DON, ADON, or charge nurse. During an interview on 6/2/23 at 1:15 PM DON stated that the RN's on shift should have done the weekly skin and wound assessment of the resident. She stated it was a rough month and multiple people were out and the skin and wound weekly assessment got missed. She stated each time she saw the resident the wound did not look to be improving or getting worse. She stated for wound care, all the employees must do is, go into the MAR and stated wound care is done. She stated they are to go into progress notes to notate if any changes to the wounds was seen. During an interview on 5/26/23 at 12:40 PM LVN-B stated that she did the wound care for Resident #1 but only on his leg. She stated she never did any wound care on his arm. She stated that wound care was split, she did wound care on the leg and RN-D did wound care on the arm. She stated that she understood that the weekly skin and wound assessment should be done by the ADON or DON if the wound care nurse was not present. She stated all she must do was click in the MAR that wound care is complete, she does not do any of the measuring or describing of the wounds. During an interview on 5/26/23 at 12:45 PM RRN-C stated that all the employees must do is fill out the MAR. She stated that no progress notes, skin notes, basically no notes were done for wound care. She stated the only reason anyone should make any notes on wound care, and they would be in progress notes, is if they see something new. She stated she is not sure why the Weekly Skin and Wound assessment was not done for Resident #1. She stated this should not have happened because this is the best way to track if a wound is improving or getting worse. She stated in the absence of the WCN-A the DON, ADON, or charge nurse should have completed this at least once weekly for each resident. She stated this is important to do because it is tracking a wound for each resident to identify if the wound is healing or not healing. During a phone interview on 5/26/23 at 1:25 PM RN-D stated that he did the wound care on the leg and on the right arm for Resident #1. He stated from the first time he saw Resident #1 to his most recent wound care; the resident's arm was just black. He stated no shearing or sluff coming off the skin was just black. He stated the wound did not really look bad to him. He stated the wound never changed, he stated the entire time the resident was under his care the wound never really improved or got worse. He stated he never did any notes of the wounds or anything in progress notes, he only initialed the MAR that wound care was complete. He stated he is not sure why the Weekly Skin and Wound assessment was not complete. He stated that the Weekly Skin and Wound assessment should be done by the wound care nurse, ADON or DON. Record review of Facilities Skin Assessment Policy and Procedure dated June 2018 revealed: Purpose: To ensure that all residents skin integrity remains intact and that all adverse skin problems are identified quickly, documented correctly, treated accordingly, and monitored for complications. Procedure: 3. All adverse skin problems must have a Skin & Wound Evaluation V5.0 (one for each site) completed and/or updated weekly to determine progress or lack thereof. The individual skin sheets are to be kept in the Treatment book until they are resolved. 676348 Page 2 of 2