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Cameron, TX – Immediate Jeopardy due to Failure to Treat and Notify Doctor About Infected Bedsores; DON Admits Doctors Orders Not Carried Out

CAMERON NURSING AND REHABILITATION

LOCATED: 2202 NORTH TRAVIS STREET, CAMERON, TX 76520

CAMERON NURSING AND REHABILITATION 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 – 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 a resident who enters the facility without pressure sores does not develop pressure sores and ensure residents having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for two (2) of nine (9) residents (Resident #3 and #7) reviewed for pressure sores when: A) The facility failed to ensure Resident # 3, a resident with a history of developing pressure sores, had a care planned pressure relieving device on her bed. The facility failed to accurately assess and stage Resident # 3’s wound to her coccyx. The facility failed to implement a physician ordered treatment change on [DATE] and failed to provide a wound treatment at all from [DATE] through [DATE]. The facility failed to notify the physician of a decline in the wound and failed to ensure pressure sores were assessed every seven (7) days as stated in their policy. Resident # 3’s pressure sore declined to a Stage IV with infection. B) The facility failed to accurately assess and stage Resident #7’s wound to his coccyx and failed to notify the physician of a decline in the wound. Resident # 7’s wound declined from a Stage II to a Stage III. This failure resulted in an Immediate Jeopardy (IJ) on [DATE].

Continuing: Observation on [DATE] at 2:40 PM revealed the DON entered a resident room to assess and measure pressure sores. The DON did not bring a cart or any sanitizing agents to the room. She did not prepare a clean surface for her supplies. She placed supplies for wound measurement under the shoes on Resident #14’s Geri chair pressure reduction pad of the incontinent resident. She then laid a pair of gloves up against the heels of the shoes and went to the bathroom to wash her hands. She returned from the bathroom and began donning gloves. She approached the resident to explain the process to the resident when the surveyor stopped the DON and instructed her to start over and explained that her articles were contaminated. Later, when the DON began assessing the heel of the resident that had a Deep Tissue Injury (Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue) she proceeded to dismiss the area and pronounced it was blanching after she placed pressure on the heel and released it multiple times. The heel was not blanching. Surveyor stepped forward and asked to see the heel turn white and then return to red. The DON applied pressure once again and admitted the heel was not changing color at all and was actually purple. The DON and ADON then tried to decide if the heel sore was a Stage I or not since it wasn’t red. The Surveyor handed the DON the in-service Wound Staging Guide as received in the training in-service and asked her to read the description of a Deep Tissue Injury. The DON then correctly identified the heel as having a deep tissue injury. DON then observed the Stage II that was approximately one (1) cm in size with a pinpoint opening on the sacrum. The DON placed the measuring device on the opening and removed it repeatedly. She finally traced the one (1) cm circle and then marked the pinpoint opening. She then placed the device back on the wound and studied it and then asked the ADON to come and see if she had marked her device correctly. The DON then began studying the raised skin edges on the bilateral buttocks and decided that those impaired skin issues needed measuring. After DON applied the graph several times, the Surveyor asked the ADON if she had told the DON that the resident had a rash over her entire perineum. The ADON said she had not informed the DON and then parted the resident’s legs so that she could see the raised skin was related to a rash and was not at all pressure sores. When the DON submitted the wound assessment to the surveyor, she had left the entire wound description area of the form blank. The Surveyor returned the form to the DON to complete it. The DON submitted it to the Surveyor the second time. The Surveyor returned the form to the DON and asked her to complete the periwound skin assessment line on the form. In an interview on [DATE] at 2:43 PM the Surveyor asked the DON as she donned gloves if she realized that she had her wound care items under a pair of shoes in the seat of a chair, she stated that she was so nervous that she did not realize what she had done. In a meeting on [DATE] at 3:15 PM the facility Administrator was made aware of the DON’s actions during the assessment of Resident # 14’s wound. The Administrator stated the DON needed more training and decided to have the two RNs performing skin assessments and not include the DON until she was further trained.

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We can help you file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262

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5 Responses to “Cameron, TX – Immediate Jeopardy due to Failure to Treat and Notify Doctor About Infected Bedsores; DON Admits Doctors Orders Not Carried Out”

  1. Kim Lenz says:

    This is very disturbing to me. My Dad was in this nursing center until he passed last month. Reading the full report that was filed by Department of Human Services, it certainly makes me wonder about all his UTI’s. Now I’m questioning as to what the cause of them really were. The staff at this nursing center are very caring people, but now I wonder at what cost were their mistakes to my Dad. Very upsetting!!

  2. Dorothy says:

    How convenient for the date to be left out .this probly happened a few years ago and the state always words it a lot worse than it is so don’t jump to conclusions

    • Anita says:

      Really if it was your family would they be exaggerating? As a nurse myself I am not sure why the DON and ADON were involved in the wound care, its not their job description.

  3. Barbara Reynolds says:

    my question were was the Dietician and the CDSM
    were was the pressure sore sheets, or wound care sheet,nutritional support, were was the lab order
    and why was the Dr”s orders not followed, the weekly or daily weights sheets,there are so many things that are wrong at this nursing home.

  4. Administrator says:

    6/27/14

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