BAYLOR SCOTT & WHITE CONTINUING CARE HOSPITAL SKIL

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet resident's medical, nursing, and psychological needs for 3 of 6 residents (Resident #2, #7, and #32) reviewed care plans. The facility's failed to include that resident had a PEG tube in Resident #32's (08/21/2025) comprehensive care plan. The facility failed to include that resident had a foley catheter in Resident #2's (07/29/2025) and Resident #7's comprehensive care plan.This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Record review of Resident #32's face sheet dated 08/21/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #32 had a diagnosis of aspiration pneumonia (a lung infection that develops from inhaling foreign substances like food, liquids, or stomach contents into the lungs.) Record review of Resident #32's admission MDS assessment dated [DATE], reflected that Resident #32 had a BIMS score of 09 which reflected the resident was moderately cognitively impaired. Resident #32's admission MDS assessment reflected that the resident had a feeding tube - nasogastric or abdominal (PEG) while a resident. Record review of Resident #32's Physician's Orders, dated 08/21/25, reflected the resident had an order initiated on 08/08/25 for: Feeding Tube Irrigation: 30 ml; per Feeding Tube Every 4 hours. Comments: Manually irrigate with additional 60 ml appropriate water type every 12 hours unless otherwise ordered by provider. Notify provider if tube gets occluded. For irrigation only. Record review of care plan dated 08/21/2025 reflected Resident #32 had not been care planned for having a PEG tube or enteral tube. In an observation and interview on 08/19/2025 at 10:43 AM Resident #32 was in bed and fall mats were placed on floor. Resident #32's call light was in reach. Resident # 32 awakened to name call but appeared very tired. Resident #32 answered that he was ok and that the staff all took good care of him. Resident #32 then went back to sleep. Resident #32 appeared clean and groomed and was in no sign of pain or distress. In an observation on 08/19/2025 at 10:57 AM, Resident #32's g-tube site was cleansed, and the dressing was changed by a staff member. No concerns were noted. Record review of Resident #2's face sheet, dated 08/21/25, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included physical debility, hypertension (high blood pressure), type 2 diabetes mellitus (a chronic condition characterized by high blood sugar levels), chronic kidney disease, intractable pain - chronic (constant pain). Record review of Resident #2's admission MDS assessment, dated 08/05/25, Section C reflected a BIMS score of 15 which indicated intact cognition. Section H reflected the resident had an indwelling catheter. Section V reflected Urinary Incontinence and Indwelling Catheter was triggered, and the decision to care plan was marked as yes. Record review of Resident #2's comprehensive care plan, initiated on 07/29/25, reflected the indwelling urinary catheter was not addressed. Record review of Resident #2's physician order, dated 07/29/25, reflected, Indwelling urinary catheter (Adult Insert and Maintain Indwelling Urinary Catheter Panel) Continuous Patient: Adult Indication (s): Acute urinary retention or bladder obstruction. Discontinue indwelling urinary catheter and order: Do not remove. Call provider when patient no longer meets criteria. An observation and interview on 08/19/25 at 11:56 AM, revealed Resident #2 sitting up in a chair, next to the bed, in her room. A catheter drainage bag hanging from the bed frame was observed. The urine in the bag was clear yellow. Resident #2 stated the staff provided catheter care regularly and she did not recall a recent urinary tract infection. Record review of Resident #7's face sheet dated 08/21/25 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included: acute hypoxic respiratory failure (a sudden and life-threatening condition where blood oxygen levels are dangerously low, often due to lung injury) and acute kidney injury (the sudden decrease in the kidneys' ability to filter waste and balance fluids, often due to infections, blood loss, dehydration, or certain medications). Record review of Resident #7's admission MDS assessment dated [DATE], reflected that Resident #7 had a BIMS score of 05 which reflected the resident was severely cognitively impaired. Resident #7's admission MDS assessment reflected that the resident had an indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of Resident #7's Physician's Orders, dated 08/21/25, reflected the resident had an order initiated on 08/07/25 for: Indwelling urinary catheter (Adult Insert & Maintain Indwelling Urinary Catheter Panel) Continuous. Record review of care plan dated 08/21/2025 reflected Resident #7 had not been care planned for having a foley catheter. In an observation and interview on 08/19/2025 at 12:06 PM Resident #7 stated she was doing good and the staff all treated her well. She stated she had a way to call for help and the staff checked on her often. Resident #7 appeared pleasantly confused and her foley catheter drainage bag hung on the walker beside resident's chair. She says the catheter did not bother her in any way and she thought the nurses took care of her catheter, but she did not know. In an interview on 08/20/25 at 1:30 PM, RN B, stated the individual nurses were responsible for initiating care plans and the care plans were an on-going process day by day as things changed. He stated peg tubes and catheters should have been care planned. He stated all nurses were trained on how to initiate and develop care plans. He stated he did not feel as though any resident would have been affected by peg tubes or catheters not being included in the care plans because the staff should have followed the physician's orders to care for the residents. In an interview on 08/21/25 at 9:33 AM, RN A stated all things such as peg tubes, nasogastric tubes and catheters should have been included in a resident's care plan. She stated nurses were trained to initiate the care plans within 24 hours after a resident admitted to the facility. She stated care plans were looked at every shift and updated on residents' condition and if there were no changes there would be no updates. She stated the nurses were not capturing everything they should have been on the care plans. She stated if a resident's care plan had not included peg tubes, nasogastric tubes, or catheters, IV's, foley or suprapubic catheters, it should not have affected a resident in a negative way because the nurses should have known by the physicians orders and assessment to care for the residents properly. In an interview on 08/21/25 at 9:41 AM, facility care plan policy was requested, RN A stated there was no care plan policy for the facility. In an interview on 08/21/25 at 10:44 AM, RN B stated some care plans could have been manually put in and they could have been developed along with the nurse assessing a resident initially. In an interview on 08/21/25 at 11:29 AM, RN C stated she was responsible for initiating and continuing care plans. She stated the care plans were created by meeting with the resident and family, reviewing the resident's medical history, by daily assessment, and by doing that she would have identified the problems that needed to be put in the care plans. She stated care plans were reviewed every shift to ensure all of the resident's problems were listed and to ensure residents goals were being met and if the residents were progressing or not. She stated she had been trained on initiating, continuing, and completing care plans. She stated things such as catheters, enteral tubes, peg tubes, nasogastric tubes, catheters, IV's, foley or suprapubic catheters should have been included in the care plans. She stated if a care plan had not included peg tubes, nasogastric tubes, IV's, foley or suprapubic catheters it could have possibly been a risk of infection to the resident but that was a basic standard of care, so it was being done. In an interview on 08/21/25 at 11:35 AM, facility care plan policy was requested, RN C stated she was unsure if there was a facility policy regarding care plans. In an interview on 08/21/25 at 11:56 AM, the DON, stated the nursing staff were responsible for initiating care plans. She stated an RN initiated the care plans and after that, all of the nurses could have added, adjusted, or tweaked the care plans. She stated care plans were created by having some standard care plans that could have been chosen and also should have included any lines or tubes or wound care initially and the maybe the day after, things such as nutrition could be ordered. She stated the nurses should have initiated care plans that bridged over to whatever the resident's diagnoses or care needed to include. She stated nursing staff had been trained on initiating and completing care plans. She stated things such as catheters, enteral tubes, peg tubes, nasogastric tubes, IV's, foley or suprapubic catheters should have been included in the care plans. She stated the residents and care plans were assessed every shift and all of the lines and tubes should have been documented on daily. She stated if a care plan had not included peg tubes, nasogastric tubes, catheters, IV's, foley or suprapubic catheters, one of those things could have possibly been overlooked. In an interview on 08/21/25 at 11:59 AM, facility care plan policy was requested, the DON stated she was unsure if there was a facility policy regarding care plans, but she was going to have that checked on at that time. 08/21/25 9:41 AM, 11:35 AM, 11:59 AM Facility policy was requested from RN A, RN C, and the DON and not received prior to exit.