**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #45) reviewed for notification of changes in that: The facility failed to ensure Resident #45's nephrostomy tube was removed as soon as medically possible. Resident #45 was first documented to have a kidney stone requiring a nephrostomy tube (an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects) and needed to see a urologist on 09/2023. Resident #45 was scheduled for surgery on 04/09/24 but the surgery was canceled due to an insurance issue the facility did not properly follow up on the insurance requirements. The facility failed to follow up with the Resident's Physician and rescheduling the surgery. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 5/25/24 at 7:05 p.m. While the IJ was removed on 5/27/25 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure prompt notification of a resident's physician and follow up for resident appointments. This deficient practice could affect residents with a change in condition and place them at risk of a delay in medical intervention, pain, and decline in health. The findings were: Record review of Resident #45's face sheet, dated 11/06/23, revealed Resident #45 was admitted to the facility on [DATE] with diagnoses of diffuse traumatic brain injury with LOC of unspecified duration (a brain injury that affects multiple areas of the brain. It is caused by the shearing of the brain's long connecting nerve fibers (axons) when the brain rapidly shifts inside the skull due to a violent blow or jolt. It can lead to coma and impairment of various brain functions. Loss of consciousness occurred for an unknown amount of time), cerebral infarction ( blood supply to part of the brain is blocked or reduced. This prevents brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes), hypertension secondary to other renal (kidney) disorders, anxiety disorder, depression, and hydronephrosis with ureteropelvic junction obstruction (part of the kidney that normally drains urine becomes blocked). Record review of Resident #45's discharge- return anticipated MDS, dated [DATE], revealed Resident #45's cognition for daily decision making was severely impaired-never/rarely made decisions. Record review of Resident #45's care plan last updated 2/5/24 revealed a problem showing Resident #45 was known to exhibit aggressive behaviors during ADL care with approach to address the resident with a calm voice, allow opportunity to make choices and participate in care, address by his name, explain in simple steps the care provided, monitor for contributing factors of irritation/aggression during care, and monitor for signs and symptoms of infection that could contribute to behaviors and follow up with MD as needed. Records review of Resident #45's physician orders, dated 4/2024, showed orders for nephrostomy site: cleanse with normal saline or wound cleanser pat dry apply skin prep, then split gauze, cover with adhesive dressing every other day or as needed, with a start date of 2/29/24 and no end date. Review of Resident #45's hospital documents from 09/14/23 to 03/22/24 showed he been hospitalized 15 times for issues with his nephrostomy. Hospital records show he was diagnosed with hydronephrosis (swelling of one or both kidneys due to a blockage that stops urine form flowing out the body. A common cause is kidney stones). Hospital records advised the resident to follow up with a specialist for surgery to remove a kidney stone. The stone was documented as 1 cm on 9/14/23 and 2.6 cm on 1/25/24 with a note that stated Please note that this is the sixth time the nephrostomy tube has been required replacement since initial placement in August 2023. Long-term percutaneous drainage is not feasible for this patient. Recommend urology consult for removal of the obstructing stone from the proximal ureter as the patient would likely no longer need percutaneous drainage once the obstruction is relieved. During an observation on 5/23/24 at 10:51 a.m. LVN A provided wound care to Resident #45's nephrostomy site and was assisted by CNA B. Resident #45 was laying on his left side. LVN A removed the bandage which covered the nephrostomy site/tube insertion into his lower back, or cleaned/dried the area with gauze, Resident #45, moaned, shouted, and kicked over the tray of supplies on the bed. Resident #45 kept moaning and grabbed CNA B as LVN A placed a new bandage over the site. LVN A held the resident's arm as she placed the bandage over the nephrostomy site. After the care was complete Resident #45 laid on his bed calmly. All previous and subsequent observations of the resident were of him laying calmly in a Geri chair with his eyes closed. During an interview on 5/24/24 at 10:12 a.m. LVN A stated the resident would normally react the same way he did during care the previous day off and on throughout the day. LVN A stated his behavior was random and had nothing to do with being in pain during care. LVN A stated she could tell if Resident #45 was in pain because of facial grimacing or he could tell you where his pain was. During an interview on 5/23/24 at 6:11 p.m. the DON stated Resident #45 did have kidney stone and stated the hospital was supposed to perform the surgery to remove the stone. The DON stated there was an insurance issue with the selected primary care provider (PCP) on his primary insurance was not the medical director of the facility and the resident had not established care with the selected PCP listed on his primary insurance. The DON stated she sent the resident's friend to the listed PCP to obtain a signed referral for surgery, but the friend was told the PCP would not sign it because he had not seen the resident. The DON stated she needed to call the insurance but had not had time because she was busy with something else for over a month and could not have her floor nurses sitting on the phone. The DON stated the resident had standing orders for pain medication and no one had ever informed her that he seemed to be in pain during care. During an interview on 5/24/24 at 3:34 p.m. Resident #45's friend stated Resident #45 had the nephrostomy tube since June 2023. She stated they have wanted to remove the stone since he got the tube placed, they just needed a specialist to say it needed to be removed first. She stated the DON told her she needs a reference number from [the insurance] company for her to get him seen by a specialist and possibly a notarized medical power of attorney so she can talk to the insurance company because the facility could not talk to the insurance company. The friend stated she had no plans to legally marry the resident due to personal reasons. The friend stated she hoped after the kidney stone was removed and the nephrostomy tube was removed the resident would be able to be taken off all the psychiatric medications that were making him heavily medicated. During an interview on 5/24/24 at 4:03 p.m. the BOM stated they had a copy of Resident 45's private insurance card. She stated the facility did not accept that insurance but they did have a copy of it. During a follow up interview on 5/25/24 at 12:15 p.m. the DON stated she received a call on 4/04/24, from the hospital about surgery to remove Resident #45's kidney stone. The DON stated the surgery was scheduled for April 9th and she was given a deadline of April 5th by the hospital to get a signed referral from the PCP listed on the insurance. The DON stated she asked Resident #45's friend who was like his family member but not legally his family to call the insurance and change his PCP. The DON stated they missed the deadline, and the surgery was canceled. The DON stated she personally had not spoken with the insurance company or done anything to follow up on the referral or if the friend changed the PCP because again, she was busy until a few days before with something else. The DON stated the previous day she had called the private insurance with the friend and heard an insurance representative tell the friend they could not release any information to her, only to the resident. The DON stated they tried to tell the insurance Resident #45 was not able to speak or make decisions and the friend was like his family, but the insurance would not release information to them and stated the friend could not make any changes to the insurance. During an interview on 5/27/24 at 3:02 p.m. the Medical Director (MD) stated he did not recall a resident under his care with a kidney stone. He stated he did recall the NP informing him of a resident who had been in and out of the hospital with complications from a nephrostomy tube, but he was sure he had seen a urologist when he went to the hospital. The MD stated he was not informed of the issues the facility was having with a referral from the insurance. The MD stated he would have been able to do a doctor-to-doctor referral or contact the insurance directly to ensure the resident still had the surgery. The MD stated it was a very broken system and he planned to contact the facility to ensure the resident received the care he needed. Record review of psychiatric service progress noted, dated 11/03/23, stated resident #45 was being seen for evaluation and management of anxiety and bipolar medications. The chief compliant from the resident was list as huh. The notes stated the patient could not answer questions logically and information was obtained from staff and his chart. Staff reports- He sustained a traumatic brain injury during a fight, patient appears to be adjusting to being in the facility. He is non-compliant with care at times but mainly when being changed . Record review of the facility's policy titled Nephrostomy Tube, Care of, dated 10/2010, stated Purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble equipment and supplies as necessary .Reporting, report any of the following signs or symptoms to the physician: 1. Redness, inflammation, reports of pain, or other signs of infection at the insertion site; 2. Reduce output or output below established parameters; 3. Inability to irrigate tube or signs of obstruction of the tube; 3. Inability to irrigate tube or signs of obstruction of the tube; 4. Signs of skin breakdown around the dressing site; 5. If the tube becomes dislodged. The DON was notified of an IJ on 5/25/24 at 6:55 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 5/26/24 at 7:36 p.m. and included the following: When residents come back with discharge paperwork, MDS Nurse and ADON will review ALL paperwork, to ensure it is complete and not missing any pages. MDS Nurse and ADON will call the hospital that the resident came from if pages are missing from the packet. For example: If the paperwork reads page 1 of 50 and only pages 1 through 42 are in the patient discharge paperwork, MDS and ADON will call to get the missing paperwork from the hospital. MDS Nurse and ADON will review discharge orders for any follow up appointments/outpatient procedures If the referral/discharge paperwork is sent via fax to the business office, the BOM or the Dietary Manager will be in charge of handing that paperwork to the MDS Nurse or ADON, if a physician's office calls the facility and the charge nurse/CNA/BOM/Dietary manager/administrator answer the phone, they are to call the MDS or ADON to take the call. Weekend charge nurses and CNAs will take a message with the call back number and then call the MDS/ADON so they could follow up with the appointments needed on Monday. **** if telephone orders are written by the NP or Physician the charge nurse will be responsible for getting the referral signed and completed and will need to be given to the MDS/ADON, for the follow-up and scheduling appointments for residents. The BOM will be in charge of making sure insurance cards are accurate and up to date, and if a resident is not self-responsible, the BOM will help the resident get guardianship/POA/DPA. MDS Nurse and ADON will know the process for identifying residents that require appointments and/or outpatient medical procedures, by being educated and trained during an in-service, the in-service will specify the importance of follow-up appointments and the MDS Nurse and ADON will also be introduced to the new log form and the binder and color of binder (GREEN) that the log will be placed in. The binder will be located in the MDS Nurse's office. All Nursing staff (Nurses and CNAs) will be in-service with our new process to ensure residents can be scheduled for any appointments/outpatient procedures. BOM, Dietary Manager, and the Administrator have all been in-serviced in our new process and are aware of the role that they play in our new process. The DON will monitor this system Monday through Friday. The administrator will be responsible for the oversight of the log, weekly (every Friday) All aspects of this process will be implemented and completed by today, Sunday, May 26, 2024. The charts have all been reviewed and completed(assessed all resident and identified any additional residents that may have been at risk) as of today, Sunday, May 26th 2024. The MDS/ADON will be in charge of the log. The director of nursing provided the staff in-service and will in-service all new hires moving forward. The surveyor verification of the Plan of Removal on 5/27/24 was as follows: Interviews with the MDS Nurse and ADON were conducted on 5/27/24. During an interview on 05/27/24 02:26 PM the ADON, was given the in service by the DON and MDS nurse. She will be in charge of phone calls regarding appointment reminders and paperwork from admission and readmits needs to be directed to MDS Nurse, DON, and herself and they make sure it gets done so there was an extra set of eyes, from her understanding they were all working together, she was in charge of making appointments and referrals, and if she was not available, staff can let MDS Nurse and DON know. They could contact her and she would make note of it but generally she was there on weekends. She stated herself the MDS Nurse, and DON are responsible. The ADON stated she would go through all the hospital paperwork, and made sure everything was transcribed correctly and made sure it's done correctly. The DON would go over to verify and they make sure it was in the logbook. They would communicate all the time. She stated, the MDS Nurse, or DON would add appointments to the logbook to include scheduled appointments and pending referrals for appointments. Interview on 5/27/24 at 2:25 PM with the MDS Nurse, revealed she verbalized an understanding of the new process in place to ensure the Res' attended or were scheduled for appointments; obtain referrals as needed. She stated her responsibility would be to follow up with any requests for appointments over the weekend. During the week she would ensure charge nurses were following through with referrals they received during shift. Interview on 05/27/24 2:12 PM with LVN A stated whenever we admit or readmit, we go through entire document with a fine-tooth comb, make sure that we received all of the pages, look for appointments, give it to the DON and ADON, the three of them including MDS Nurse, She is also in charge of getting referrals signed by the doctor. Interview on 05/27/24 2:22 PM medication aide C if someone calls about a resident they would take the information down unless MDS Nurse or ADON are here, then we would forward the call to them or call and tell them if they are not here. Interview on 5/27/24 at 2:15 PM with CNA D revealed she had worked at the NF since 2006, M-F 6AM to 2PM. She stated she did not have any responsibilities for ensuring Residents were scheduled for apts. However, if she answered the phone and her charge nurse was not readily available, she would take down the caller's info, the resident's info, and details of call. She would then provide it to her charge nurse and or the MDS Nurse or the ADON. Interview on 5/27/24 at 2:17 p.m. with CNA E stated MDS called me yesterday. She said if we answer the phones and if someone wants to tell us about an appointment, we would call the nurse to the phone. If the nurse is busy, we will take a message with the name and number of the person calling so the nurse can call them back. If a resident tells us about an appointment, we would report that to a nurse so she can get all the information. Interview on 5/27/24 at 2:26 p.m. with CNA F stated MDS texted me and then she called me. She said if we get a phone call then to let either MDS or the ADON know. Take down the doctor's name and phone number and appointment information. Then we will give it to MDS Nurse or ADON or I will let the nurses know. Interview on 5/27/24 at 2:29 p.m. with CNA G stated I got a call from MDS yesterday. If we receive any information about doctor appointments, we have to notify MDS Nurse or the ADON. I don't ever answer phones - I will pass call to charge nurse. I would take a message if the nurse were busy. Interview on 5/27/24 at 4:00 PM with the BOM revealed she would transfer a call to MDS/ADON pertaining to a Resident/apt or referral if readily available. If not she would take a detailed written message and deliver it to the charge nurse, MDS nurse and or the ADON. She would confirm all pages for faxes were received. If not would call to let sender know did not receive the complete fax. Then would deliver any faxes having to do with resident care to the charge nurse, MDS nurse and ADON. Interview on 05/27/24 at 6:58 p.m. the dietary manger shares an office with the BOM where the fax machine is located. She will monitor for incoming faxes and provide them to nursing. Interview on 05/27/24 2:12 PM with LVN A, B hall charge nurse confirmed she will complete referrals by obtaining signatures and giving it to the ADON, DON, or MDS nurse. Interview on 05/27/2024 at 5:50 p.m the BOM stated she would make sure she kept insurance cards up to date she would update the book when they come in and add notes in their files with what insurance they are under. If a resident cannot speak for themselves or not handle medical decisions or find them a guardian or POA or who they designate to represent them and if they cannot afford an attorney, she would assist with getting social security so they can have funds or get a Pro bono attorney. She had a website address where they could apply for guardianship. She also did contact the ombudsman for resource and HHSC for guardianship resources. Interview On 05/27/24 at 1:17 PM The Administrator stated he had a calendar and would put appointments on the calendar. He stated they would check with the insurance and pending surgery. He stated he was going to get the Ombudsman involved to see if they can assist with getting information. Interview 05/27/24 11:03 AM with the DON, her POR, meant that when residents were coming from hospital the MDS Nurse and ADON would get the discharge paperwork together and will make sure it is the complete record like all pages, MDS Nurse and ADON would review the discharge paperwork for any appointments and referrals. The DON stated the reason it was both MDS Nurse and ADON was just in case one of them is out. Our BOM and dietary manager would monitor if anything comes in the fax or mail, they would bring it to nursing right away to MDS Nurse or ADON. Whoever answers the phone for outside providers calling for appointments, would transfer the call to the MDS Nurse or ADON, on weekends they would make sure they have a call back number and the give the ADON or the MDS nurse on call. The charge nurse was to make sure referrals had signatures for referrals, if NP was there, she would sign or fax to MD if needed right away and follow up and give to the ADON or the MDS Nurse, The BOM would document in medical charts if she was completing social worker task like following up with insurance or helping schedule appointments, or making arrangements for appointment of residents to be seen in the facility by dental or vision. Record review of Resident #45 revealed he was sent out to the hospital on 5/26/24 due to his nephrostomy tube being dislodged and he would be receiving surgery for removal of the kidney stone. Record review of a document, titled Hospital Surgery/MD/Specialist Follow up Appointments, no date, was verified on 05/27/24, and the log contained 6 appointments for residents. Record review of the untitled Inservice revealed 32 staff were in serviced on 05/26/24 in person if they were present at work or through text and responded to confirm they received the text. 20 staff were texted about the in service, some later came to work and were interviewed by surveyors. On 5/27/24 at 7:10 p.m., the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of potential harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.