Health inspection·August 31, 2023

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 includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents, Resident #105 (R #105), reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for R #105, use of anticoagulant medication. This deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings: Record review of R #105's Face Sheet revealed an [AGE] year-old female, with an original admission date of 12/22/2022. Diagnoses included, Type 2 diabetes (insufficient production of insulin in the body), Atherosclerotic Heart Disease (arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), and cardiac pacemaker (small battery powered device that prevents the heart from beating too slowly), and Hypertension (high blood pressure). Record review of R #105's Quarterly Minimum Data Set, dated [DATE] revealed R #105 had a BIMS (Brief Interview Mental Status) of 06 (Severe Impairment) and requires Extensive Assistance with transfers and limited assistance with bed mobility, eating, toilet use, dressing, and personal hygiene. Record review of R #105's Care Plan dated 8/17/2023 revealed no care plan for anticoagulants. Record review of R #105's MDS had no indication of anticoagulant use. Record review of R #105's orders stated; -Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention dated 6/29/2023 -Anticoagulant Medication Side Effect Monitoring- Code the following if identified:0-None, 1- Discolored Urine, 2- Black Tarry Stools, 3- Sudden Severe Headache, 4- N&V (nausea and vomitting), 5(continued on next page) Page 1 of 2 676465 676465 08/31/2023 Las Alturas Nursing & Transitional Care 4301 North Bartlett Avenue Laredo, TX 78041

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Diarrhea, 6- Muscle Joint Pain, 7- Lethargy, 8- Bruising, 9- Sudden change in Mental Status 10- Vital Signs, SOB, Nose Bleeds every day shift dated 8/30/2023 Interview on 08/30/23 at 03:03 PM DON stated he looked through care plan for R #105 and revealed Plavix (Clopidogrel) is not shown to be care planned and should be. DON stated medication such as anticoagulants should be care planned by MDS Corridinator as it was person-centered and direct care staff need to be able to identify any adverse effects of anticoagulants and potential side effects such as bruising, bleeding or any other complications. Interview on 8/31/2023 at 10:29 AM with MDS (minimum data sheet) Coordinator stated all anticoagulants should be care planned for any resident receiving anticoagulant medications MDS Coordinator stated R #105's anticoagulant medication was missed and no reason why it was not care planned other than human error. MDS Coordinator stated anticoagulants are care planned so that all staff would be aware of the risk factors associated with such medications. MDS Coordinator stated, since medication was not care planned, staff would be unaware of the potential side effects of bruising and bleeding. MDS Coordinated stated R #105's Care plan has been updated as of 8/30/2023. Record review of Care Plan Policy dated 2/2017 and revised on 3/2020 indicated; The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan: -is developed within seven days of the completion of the comprehensive assessment; -is prepared by the interdisciplinary team, including the attending physician, a registered nurse with responsibility for the resident, and other appropriate team members in disciplines as determined by the resident's needs. The care plan reflects intermediate steps for each outcome objective if they will enhance the resident's ability to meet his or her objectives. Team members use these objectives to monitor resident progress. 676465 Page 2 of 2