OAKWOOD NURSING AND REHABILITATION LP
LOCATED: 301 WEST RANDOL MILL RD, ARLINGTON, TX 76011
OAKWOOD NURSING AND REHABILITATION LP 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 interview, record review, and observation, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible for eleven (Residents #6, #14, #16, #19, #20, #21, #22, #28, #29, #30, and #33) of 39 residents, who were reviewed for supervision to prevent accidents.
1. The facility failed to provide adequate supervision of Resident #14, who was known to display aggressive behaviors and to run into other residents with her walker. On 05/05/15, Resident #14 ran into Resident #6’s leg with her walker causing a large hematoma, which required the resident to be transferred to the hospital for evaluation and treatment. The failure resulted in Resident #14 sustaining a large hematoma to her right lower leg which required hospitalization.
2. The facility failed to provide adequate supervision to prevent Resident #24 from physically abusing other residents. On 04/18/15, Resident #20 was punched in the chest by Resident #24. Resident #20 did not sustain injury as a result of being hit. The resident reported the incident to the local police department. Prior to this incident, Resident #24 hit Resident #21 on the top of the head. The failure to provide adequate supervision to prevent resident-to-resident abuse could result in injury, fear, withdraw, and isolation.
3. The facility failed to prevent the elopements of two confused residents and failed to ensure there was a system in place to check the WanderGuard bracelets of those residents identified as being elopement risks. The facility also failed to ensure the gate leading away from the smoking area was locked to prevent residents from leaving the facility unsupervised. On 05/03/15, Resident #19 eloped from the facility and was found at a business establishment across from the facility. On 04/06/15, Resident #16 eloped from the facility and was found by police officers at a fast food restaurant located 0.2 miles from the facility. Both residents were found on the other side of a busy, four-lane road with a speed limit of 40 miles per hour, and neither resident sustained [REDACTED]. The facility failed to ensure WanderGuard bracelets were in place and/or functioning for the following six residents, who were identified as being at risk for eloping, Residents #14, #22, #28, #29, and #30, and #33. The failure had the potential to result in residents, with cognitive deficits, eloping from the facility and potentially being injured or seriously harmed. An Immediate Jeopardy (IJ) was identified on 05/07/15. While the IJ was removed on 05/11/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility still monitoring the effectiveness of the Plan of Removal.
Continuing: A confidential interview on 05/07/15 at 12:50 p.m. with a facility nursing employee revealed the residents, who were being admitted to the facility, were not appropriate for the facility due to their behaviors affecting others. He/She stated those residents fought others, and they needed to be watched closely by staff; however, the staff could not be everywhere they needed to be so the other residents paid for it. He/She stated the facility was more concerned with filling the beds and not taking into consideration the behaviors or histories of these residents. The nursing employee stated there were problems with resident behaviors at the facility, and the facility administration was aware of the problem, but it was not addressed. He/She stated the facility was not able meet the residents’ needs, and it was not safe at the facility.
Continuing: The Administrator denied knowing of the incident regarding Resident #20 being punched in the chest on 04/18/15. He stated he was unaware the police were called to the facility at the time of the incident. He stated the incident should have been called into the State, but first of all, should have been reported to him. The Administrator stated he did not understand, and shook his head.
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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