Health inspection·May 30, 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 observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 17 residents (Resident #30, #31, and #97) reviewed for care plans. -The facility failed to develop and implement a comprehensive care plan for Resident #30 for cardiac telemetry status (a monitoring system that tracks electrical activity of the heart using electrodes and a monitor). -The facility failed to develop and implement a comprehensive care plan for Resident #30, #31, and #97 for the use of bedrails. This deficient practice could place residents at risk of not receiving proper care and services. Findings included: Record review of Resident #30's face sheet dated 05/31/2024, revealed an [AGE] year-old admitted to the facility on [DATE]. Resident #30's diagnoses included a fracture of the upper left arm, muscle wasting, Parkinson's disease (a progressive disorder that affects the nervous system), dementia, heart failure, hyperlipidemia (abnormally high levels of fats in the blood), sprain of left wrist, bradycardia (heart rate slower than 60 beats per minute), hypertension (elevated blood pressure), presence of cardiac pacemaker, and history of falling. Record review of Resident #30's annual MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Resident #30 had impairment to one side of the upper extremity and used a walker for mobility. Resident #30 required partial assist from a helper with bed mobility and personal hygiene. Resident #30 required substantial assist with sitting to lying, sitting to standing, as well as toileting and transfers. Resident #30 was receiving physical therapy. Section P: Physical Restraints, of the MDS indicated the bed rail was not used. Further review of the MDS revealed a fall history in the last month. Record review of Resident #30's order summary report dated 05/29/2024 at 2:22 PM revealed a verbal order dated 05/06/2024 to put the resident on telemetry. Record review of Resident #30's physician progress note written by the MD, dated 05/29/2024 at 8:13 AM, revealed Resident #30 had bradycardia and the plan included to monitor telemetry. Page 1 of 5 676420 676420 05/30/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #30's pulse summary revealed the remote telemetry system was continually recording heartbeat at least every hour beginning 05/06/2024 at 10:56 PM. Record review of Resident #30's Bedrail Assessment, with the effective date of 03/14/2024 and signed by LVN A revealed side rails/assist bar were indicated and served as an enabler to promote independence. Residents Affected - Few Record review of Resident #30's undated Side Rail Assessment and Consent revealed the type of rails to be used were: top half and two sides. The Consent was signed by Resident #30's family. Record review of Resident #30's undated care plan did not address the use of telemetry or bedrails. Further review indicated Resident #30 required 1-2 staff assistance with all ADL's, date initiated was 03/15/2024. Record review of Resident #31's face sheet dated 05/29/2024 revealed a [AGE] year-old admitted to the facility on [DATE] with diagnoses to include critical illness myopathy (a condition of muscle weakness that affects critically ill patients), Diabetes, chronic kidney disease, hyperlipidemia, hypertension, gastrostomy status (g-tube for feeding), Bell's palsy (a condition that causes temporary weakness or paralysis of the muscles in the face), and polyneuropathy (damage to multiple peripheral nerves). Record review of Resident #31's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #31 had no impairments to both upper and lower extremities. Resident #31 was independent with bed mobility. Resident #31 required set up only for transfers. Section P of the MDS indicated bed rail was not used. Record review of Resident #31's undated care plan did not address the use of bedrails. Further review indicated Resident #31 required 1-2 staff assistance with all ADL's, date initiated was 02/22/2024. Record review of Resident #31's Bedrail Assessment, with the effective date of 02/22/2024 and signed by the DON revealed side rail placement recommendations were for the left side and side rails/assist bar were indicated and served as an enabler to promote independence. Record review of Resident #31's undated Side Rail Assessment and Consent was signed by Resident #31. Record review of Resident #97's face sheet dated 05/29/2024 revealed a [AGE] year-old admitted to the facility on [DATE] with the diagnoses to include encephalopathy (damage or disease that affects the brain), periprosthetic fracture (broken bone) around a hip or knee joint replacement, atrial fibrillation (irregular, rapid heart rhythm), heart disease, cardiac pacemaker, obesity, seizures, history of falling, and abnormal reflex. Record review of Resident #97's admission MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #97 had impairment on both sides of upper extremities and used a walker for mobility. Resident #97 was dependent on staff for toileting and dressing. Resident #97 required partial assistance with bed mobility and substantial assistance with sitting to lying, lying to sitting on the side of the bed, and sitting to standing positions. Resident #97 had a fall in the last month and had a fracture related to a fall in the last 6 months. Section P of the MDS indicated bed 676420 Page 2 of 5 676420 05/30/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0656 rail was not used. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #97's undated care plan did not address the use of bedrails. Further review indicated Resident #97 required 1-2 staff assistance with all ADL's, date initiated was 05/23/2024. Residents Affected - Few Record review of Resident #97's Side Rail Assessment and Consent dated 05/23/2024 revealed risks and benefits were explained to the resident/family, including the risk of significant injury if a fall occurred. The Consent was signed by Resident #97's family and RN B. Observation and interview on 05/28/2024 at 12:45 PM, Resident #30 was sitting up in the wheelchair and was connected, with electrodes, to the cardiac telemetry monitoring system. There were bedrails attached to both sides of the bed frame and the bedrails were in the down position. Resident #30's family stated that he was on telemetry because he had issues with his heart. In an interview on 05/28/2024 at 3:59PM the DON stated all data for the telemetry residents goes directly into point click care. She stated it was the responsibility of the MDS and the DON to ensure that the care plans were updated. She stated all residents that are receiving telemetry, should be care planned because it is an intervention for cardiac. She stated the care plan should be updated when the orders were received. In an interview on 05/29/2024 at 3:53 PM, the DON stated telemetry should be in the resident care plan and that the MDS nurse and the ADON were responsible for making sure it was care planned. The DON stated it should be included in the care plan because it was an intervention for cardiac issues and should be updated when the order was received. In an interview on 05/29/2024 at 4:42 PM, the MDS nurse stated that telemetry was not required to be care planned d/t it was a service the facility provided. The MDS nurse stated the nursing staff would not know if the resident was on telemetry if they were to check the care plan. The MDS nurse stated there was no code for telemetry in the MDS, that it was not billed, and there was no place in the MDS to bill for it. In an interview on 05/30/2024 at 12:06 PM, the ADON stated the facility did not give bedrails unless the resident had a high BIMS score to be able to communicate their needs for them or if physical therapy evaluated the need for bed rails. The ADON stated demi rails were equivalent to a shower rail in the bathroom. The ADON stated demi rails were not care planned but the bigger bed rails that would be exit limiting would be care planned. Observation and interview on 05/30/2024 at 12:40 PM, Resident #31 was in bed with the HOB raised and there was a short grab bar to his left side that was raised. Resident #31 stated the grab bar was already on the bed when he first admitted , and it was helpful when he needed it. Observation on 05/30/2024 at 12:48 PM, Resident #30 was lying on his back in bed asleep with the HOB raised. Both side rails were connected to the top half of the bed frame and were in the raised position. In a telephone interview on 05/30/2024 at 2:11 PM, the NP stated he believed Resident #30 had atrial fibrillation and bradycardia and that was the reason he wanted him on telemetry. 676420 Page 3 of 5 676420 05/30/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 05/30/2024 at 2:35 PM, RN C stated Resident #30 had left side weakness and the bed rails were there to help with bed mobility. RN C stated Resident #97 also had left side weakness and used the bed rail for bed mobility. RN C stated that the bed rails should be written in the care plan but did not know if this was the facility policy and procedure. RN C stated she believed the residents benefit from the bed rails and it would be a negative if they were considered restraints. RN C stated it was important to include in the care plan because if a resident can use the bedrails to move around it could help prevent skin injuries and could help protect and promote independence. RN C states she believed Resident #31 had the bed rail assist early on when he was very dependent. RN C stated she did believe bed rails were considered a restraint in the facility and that any full bed rail would be a restraint. RN C stated a full bed rail would be at least ¾ the length of the bed. RN C stated Resident #30 had bed rails to both sides of the upper part of the bed and Resident #97 had loop bars on both sides. RN C stated Resident #31 had a loop bar and that when he first came to the facility, he could not reposition himself in the bed. She stated he could not get up at all and required 2-person assistance but was now walking and transferring himself. In an interview on 5/30/2024 at 3:04 PM, the DON stated Resident #30 needed the bed rails upon admission. In an interview on 05/30/2024 at 3:51 PM, the MDS nurse stated Residents #30, #31 and #97 did not have bed rails and that bed rails restrict movement. MDS nurse stated Residents #30, #31 and #97 had mobility bars that did not restrict movement. MDS nurse stated if they used bedrails then she would code them as such, and assessments and consents would be needed. In an interview on 05/30/2024 at 4:12 PM, Resident #30's family stated the bed rails had always been on the bed and that it helped him get out of bed because of the height. The family stated Resident #30 had shoulder replacement and had difficulty getting out of bed without the bed rails. When asked if Resident #30 was restricted by the bed rails, the family stated it did not because it helped him. In an observation and interview on 05/30/2024 at 4:25 PM, Resident #97's family stated the bed rails were discussed with the facility and it helped with his movement to get out of bed. The family stated in the past he did not need it but now he needed it. Resident #97 was in bed and the bed had a loop/grab assist bar mounted to the bed frame. In an interview on 05/30/2024 at 4:51 PM, the CCO stated bed rails should be addressed in the care plan, in the ADLs, and the risks would depend on the reason for the use such as left sided weakness. Record review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered, revised on March 2022, read in part: .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are a. provided by qualified persons .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Record review of the facility policy and procedure for Bed Safety and Bed Rails, revised August 2022 read in part: .Use of Bed Rails, 1. Bed rails are adjustable metal or rigid plastic bars that 676420 Page 4 of 5 676420 05/30/2024 The Brightpointe 604 S Conroe Medical Dr Conroe, TX 77304

F 0656 Level of Harm - Minimal harm or potential for actual harm attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths .For the purpose of this policy bed rails include: a. side rails; b. safety rails; and c. grab/assist bars . Residents Affected - Few 676420 Page 5 of 5