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RAINBOW HEALTH CARE – FALL IGNORED BY STAFF

RAINBOW HEALTH CARE COMMUNITY LOCATED: 111 EAST WASHINGTON, BRISTOW, OK 74010 RAINBOW HEALTH CARE COMMUNITY was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility’s failure to intervene when a resident began showing signs and symptoms of increased intracranial pressure. The resident fell and hit her head on [DATE]. The resident expired on [DATE] due to a subdural hematoma from [MEDICATION NAME] force trauma of the head. At 4:00 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. At 4:02 p.m., the administrator was notified of the IJ situation related to the facility’s failure to intervene when a resident began showing signs and symptoms of increased intracranial pressure. Based on interview and record review, it was determined the facility failed to intervene for a resident when they began showing signs and symptoms of increased intracranial pressure after a fall for one (#4) of six sampled residents who were reviewed for changes in condition. The resident fell and hit her head on [DATE] at 10:30 a.m. The resident begain exhibiting signs and symptoms of increased intracranial pressure at 3:00 p.m. 911 was called at 5:50 p.m. The resident’s physician was not notified of the symptoms of increased intracranial pressure until 6:00 p.m., when the resident was transfered by ambulance to the hospital. The resident expired on [DATE] due to a subdural hematoma from [MEDICATION NAME] force trauma of the head. The facility identified 70 residents who resided at the facility. Review of the clinical record revealed no documentation the facility intervened or that they notified the physician when the resident first began showing signs of increasing intracranial pressure at 3:00 p.m. through 5:32 p.m. The resident had developed a headache, had an increasing blood pressure, and had developed nausea, all symptoms of increased intracranial pressure. The neurological flow sheet, dated [DATE] at 5:40 p.m., documented the resident’s blood pressure had increased to, [DATE] and her heart rate was 92. It was documented the resident had snoring respirations at 14 to 16 per...

TOWN AND COUNTRY MANOR – RESIDENT CHOKES AND DIES...

BOERNE, TX– RESIDENT ON PRESCRIBED SOFTENED DIET CHOKES AND DIES AFTER STAFF GIVES WRONG FOOD TRAY TOWN AND COUNTRY MANOR LOCATED: 625 N MAIN ST, BOERNE, TX 78006 TOWN AND COUNTRY MANOR was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for 1of 5 residents (#1) who were reviewed for accidents in that: The facility failed to feed Resident #1 when he should have been fed and was served cut up pieces of sausage instead of ground meat. As a result, Resident #1 choked on pieces of meat and died due to asphyxiation. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern until all residents were assessed and staff was in-serviced. Review of an emergency provider report dated [DATE] revealed that Resident #1 had a cardiac arrest after choking on a piece of meat at the nursing home. Per EMS, pt. was found unresponsive after choking at 1800 today. EMS pulled out a lot of food out of our pt. as they intubated him. They do not know if someone performed the Heimlich maneuver. They were doing CPR when EMS got there. The provider report also assessed the resident with: Symmetric dilated pupils and face is cyanotic; and ET tube present with food debris in tube. The emergency physician determined that: Primary impression: Aspiration into airway. and Secondary impression: cardiac arrest. Time of death called at 1855. Review of Resident #1’s tray card dated [DATE] revealed the resident was to be served dysphagia advance (textured) meals on a lip plate. During an interview on [DATE] at 12:05 p.m., the Food Service Manager stated that although she was not in the building on [DATE], she interviewed the cooks preparing the evening meal and they reported that Resident #1’s tray was not served...

PRUITTHEALTH–CRESTWOOD: FAMILY STATED, “NO ONE RESPONDED” TO THEIR CALL FOR HELP.”...

PRUITTHEALTH – CRESTWOOD LOCATED: 415 PENDLETON PLACE, VALDOSTA, GA 31602 PRUITTHEALTH – CRESTWOOD was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to provide care and services in a timely manner for one resident (R#39) of 28 sampled residents. Resident (R) #39 was found unresponsive to voice and touch on 4/4/16. The nurse failed to assess and provide treatment to the resident. R#39 was transported to the hospital via ambulance four hours after the initial nursing assessment. This standard was cited at harm level. On 2/28/17 at 11:35 a.m., an interview with complainant in R#39’s room stated, my sister received a call to come see about our mother. I was just coming to visit and she (R#39) was non- responsive in her room in the bed. Pushed the call light and no one responded. Told a CNA (Certified Nursing Assistant) to go get LPN HH. She never came. I went to go find LPN HH. LPN HH tried to wake her up and I insisted that she call 911. Someone finally called 911. One of the hospital nurses said that she (R#39) had been given too much medicine. They gave her [MEDICATION NAME] (treats narcotic overdose) more than once to bring her back. Review of nurse’s notes dated 4/3/16 at 2:50 p.m., for R #39 revealed Resident noted c (with) slight SOB (shortness of breath) .placed on 3 (three) day charting for observation. Will cont. (continue) to observe. There was no documentation indicating LPN HH assessed nor provided recommended interventions for R #39 at that time. Nurse’s notes dated 4/3/16 at 4:30 p.m., revealed Blood sugar 238, resident non-responsive to physical or verbal stimuli, 10 units [MEDICATION NAME] (insulin) given .Family at bed side. The nurse’s note lacked documentation indicating R#39’s oxygen level was being monitored due to the display of SOB. The following events were documented on 4/3/16: At 4:45 p.m., R#39 remains unresponsive O2 sat @ (at) 88% on 3L (three) O2. (The physician’s orders [REDACTED]. 5:30 p.m., Daughter called this nurse into see resident. Unable...

CLAIRMONT LONGVIEW -RN A TOLD HIM THAT SHE GAVE RESIDENT #1 A SANDWICH AND ASKED CNA D “NOT TO TELL ANYBODY”...

CLAIRMONT LONGVIEW LOCATED: 3201 N FOURTH ST, LONGVIEW, TX 75605 CLAIRMONT LONGVIEW was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 8 residents reviewed for neglect (Resident #1) was free from neglect. The facility did not ensure Resident #1 received the physician ordered diet. Resident #1 had orders for a pureed diet, and ate a peanut butter sandwich. Resident #1 choked on the sandwich which likely contributed to his death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated actual harm due to the facility’s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 38 residents receiving mechanically altered diets, including pureed diets, at risk for harm or death. A physician progress notes [REDACTED] #1 had dysphagia and required aspiration precautions. During an interview on [DATE] at 3:31 p.m., CNA C said on [DATE] she was working on the secure unit. She said between 8:45 p.m. and 8:55 p.m., she saw Resident #1 sitting in a chair with a bed side table in front of him, by the nursing station of Hall 100. She said they spoke to each other and then she went into the secure unit. She said approximately, [DATE] minutes later, she came out of the secure unit and Resident #1 was lying across the bedside table, his eyes and mouth were open, and his lips were blue. She said she began screaming at the 2 nurses sitting behind the nursing station that Resident #1 was blue. She said she pulled Resident #1 from the chair and began performing the [MEDICATION NAME] maneuver. She said a piece of bread that smelled like peanut butter came out of his mouth. She said the nurses began CPR and EMS arrived. She said the nurses were seated behind the nursing station and they could not have seen Resident #1 where he was seated. She said the snack tray that included peanut butter sandwiches were...

HOSPITAL NOTES, “CAME FROM NH WITH BEDSORES, CRUSTY CATHETER, DRIED BOWEL MOVEMENT ON SKIN AND BRUISES”...

FOREST HILLS CARE AND REHABILITATION CENTER LOCATED: 4300 WEST HOUSTON, BROKEN ARROW, OK 74012 FOREST HILLS CARE AND REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES. LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to identify and provide treatment to prevent the development of an avoidable pressure ulcer for two (#375 and #385) of three sampled residents who were reviewed for pressure ulcers. The facility identified 12 residents who had pressure ulcers. Resident # 385 had multiple untreated unstageable pressure ulcers to his buttocks and penis. A history and physical report from the hospital, dated 01/19/17 at 3:54 a.m., documented, .patient’s nursing home staff noticed that his urine was darker than normal and they thought he might be getting dehydrated or have a urine infection so he was subsequently transferred to (hospital name deleted) for further evaluation and treatment .Skin: warm and dry color appropriate in all limbs. No [DIAGNOSES REDACTED], or induration on exposed observed areas of head, neck, and limbs. A case management discharge planning note from the hospital, dated 01/19/17 at 2:08 p.m., documented, nursing staff informed that they are very concerned about possible abuse/neglect while at the nursing home .pt is very excoriated on his bottom and has an unstageable pressure ulcer on his bottom as well. pt’s catheter does not appear to have been cared for .pt has a pressure ulcer on his penis. A hospital progress note, dated 01/19/17 at 4:36 p.m., documented, .Pt came from NH with unshakeable (sic) wound on sacrum, and one on tip of penis also has blister on left heel. His f/c very crusty and peri area red with blisters and dried bowel movement on skin .also has bruising around waist. Wound consult ordered. A hospital medical discharge summary, dated 01/28/17, documented, .Discharge [DIAGNOSES REDACTED].sepsis present on admission secondary to the above .multiple unstageable decubitus ulcer. At 11:35 a.m., LPN #2 was asked when she was aware of the skin breakdown on the resident’s sacrum and coccyx. She stated It was about nine p.m., on the evening he was transferred....

STAFF STATES,” FORMER ADMINISTRATOR JUST WALKED OUT OF THE ROOM AND NEVER ACKNOWLEDGED THAT WE TOLD HIM ANYTHING.”...

SIGNATURE HEALTHCARE AT JACKSON MANOR REHABILITATION & WELLNESS LOCATED: 96 HIGHWAY 3444, HOUSTON, ANNVILLE, KY 40402 SIGNATURE HEALTHCARE AT JACKSON MANOR REHABILITATION & WELLNESS was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO 1) HIRE ONLY PEOPLE WITH NO LEGAL HISTORY OF ABUSING, NEGLECTING OR MISTREATING RESIDENTS; OR 2) REPORT AND INVESTIGATE ANY ACTS OR REPORTS OF ABUSE, NEGLECT OR MISTREATMENT OF RESIDENTS. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility’s policy it was determined the facility failed to ensure allegations of abuse were thoroughly investigated, failed to ensure residents were protected from further abuse, and failed to report allegations to state agencies as required, for one (1) of two (2) sampled residents (Resident #2). Facility staff reported to the former Director of Nursing (DON) and the former Assistant DON on [DATE] that Resident #1 was observed to take Resident #2’s hand and place it on his/her private part and rub himself/herself. The facility failed to conduct an investigation related to the alleged incident, failed to protect residents from further abuse, and failed to report the alleged incident to state agencies. The facility’s failure to ensure allegations of abuse were thoroughly investigated, failure to ensure residents were protected from further abuse, failure to ensure abuse allegations were reported to state agencies, as well as failure to review/revise residents’ plans of care when inappropriate sexual behavior was observed, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility submitted an acceptable Allegation of Compliance (AOC) on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. Based on the State Survey Agency’s (SSA) validation of the AOC it was determined the Immediate Jeopardy was removed on [DATE] prior to the SSA initiating the investigation on [DATE]; therefore, it was determined to be Past Immediate Jeopardy. Interview on [DATE] at 3:45 PM with the Assistant Business Office Manager revealed she had witnessed Resident #1 take Resident #2’s hand and place it on his/her private part and rub himself/herself on [DATE]. She stated she felt the incident was potential abuse and immediately reported the incident...