Health inspection·March 29, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 2 of 3 residents (Resident #'s 1 and 4) reviewed for plan of care revision. The facility failed to include in the care plan a right foot brace/pose brace for Resident #1. The facility failed to include in the care plan, Behavioral Interventions for Resident #4. This failure could place the residents at risk of decline in health status and unmet physical and psychosocial needs due to the staff and providers not having the most current information for the Resident's plan of care. Findings include: Record review of Resident # 1's face sheet dated 3/28/24 revealed he was an [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: osteoarthritis, unsteadiness on feet, muscle weakness, and lack of coordination. It was not updated to include the diagnosis of peroneal palsy and the associated symptom of right foot drop. Record review of Resident #1's physician orders dated 02/05/24 revealed the following: posey to right foot bootie at all times until AFO (ortho ankle foot orthosis) Brace arrives. The order was discontinued on 03/01/24. A physician order for the diagnosis of peroneal palsy (a mononeuropathy of the lower extremity that can be debilitating with symptoms ranging from mild sensory loss to severe pain and foot drop) was added 0n 02/14/24. Resident needs AFO brace to right ankle. Record review of physician orders dated 03/28/24 revealed: Resident has AFO brace to right foot remove and assess skin daily. Record review of Resident #1's electronic health record revealed the most recent comprehensive care plan dated 03/20/24 did not contain revisions for a Right foot brace. Record review of Resident #1's admission MDS dated [DATE] revealed the following: section C documented Resident # 1's BIMS was 15, section GG documented the resident was wheelchair bound, section I documented the resident had a diagnosis of other neurologic condition, and section O Restraint or brace assist was marked no. Interview and observation with Resident #1 on 3/28/24 at 12:30 PM revealed he was wearing the brace to his rt foot. He stated therapy did not always reapply the brace after his daily therapy session Page 1 of 2 676415 676415 03/29/2024 Sheridan Medical Lodge 1119 S. Red River Expressway Burkburnett, TX 76354

F 0657 he stated he did not really care about wearing the brace, but his daughter insisted. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #1 family member on 3/28/24 at 1:30 pm revealed the family member visited the resident daily. She stated the therapy department encouraged the resident to go without the brace and did not think he needed the brace. Residents Affected - Some Interview with the occupational therapist on 3/28/24 revealed she was aware of the order for the right foot brace written by Resident31's neurologist, but she did not think the resident needed the right foot brace. She stated she believed the foot drop would improve with exercise. Record review of Resident # 4's face sheet dated 3/28/24 revealed she was an [AGE] year-old female who was most recently admitted to the facility on [DATE] with the following diagnoses: Dementia without behavioral disturbances, schizoaffective disorder, and Psychosis. Record review of Resident #4's physician orders dated 02/05/24 revealed the following: Psychoactive medication behavior monitoring: the resident takes Lexapro, buspirone, and trazodone for diagnoses of depression and insomnia. Document any behaviors or side effects every shift. Record review of Resident # 4's Quarterly MDS assessment dated [DATE] Section E documented Resident #4 had no physical behavioral symptoms, but exhibited verbal behavioral symptoms (threatening, screaming, or cursing) at others. Section C revealed her BIMS score was 7 which indicated moderate cognitive impairment. Record review of Resident #4's electronic health record revealed the most recent comprehensive care plan dated 03/28/24 did not contain revisions for resident behaviors or behavior monitoring. Interview on 03/28/24 at 1:00 pm with the DON revealed it would be her expectation that the care plan should include a focus area for application of the right foot brace for Resident #1, and a focus area for behaviors on Resident #4. She stated the care plan should be updated by the MDS nurse. She stated failure to update the care plan could result in the resident not receiving the care he needs. She stated the care plan had not been revised to include the diagnoses of peroneal palsy or the intervention of a foot brace for Resident #1 and Resident #4's behavior She stated the care plans were not updated and they should have been updated for Res, but they should have been revised. She stated it was the MDS nurse responsibility for updating the care plans and she had not checked them to see that all areas were addressed for Resident #'s 1 and 4. Review of the facility policy and procedure for Comprehensive Person-Centered Resident Care Planning, not dated, revealed the following [in part]: Each resident's plan of care shall be periodically reviewed and revised by an interdisciplinary team after each MDS assessment, including both the comprehensive and quarterly review assessments to reflect the resident's current care needs . 676415 Page 2 of 2