COLONIAL TYLER CARE CENTER
LOCATED: 930 S BAXTER, TYLER, TX 75701
COLONIAL TYLER CARE 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, the facility failed to ensure necessary treatment and services were provided based on the comprehensive assessment to promote healing and prevent new injuries from developing for 1 of 2 residents reviewed for pressure injuries. (Resident #2)
The facility did not provide treatments for Resident #2’s stage 4 pressure injuries on his left ischium (gluteal fold) and sacrum area for 2 days and did not provide weekly assessments. The pressure injuries worsened in size and had a foul odor.
The resident developed a new stage 2 pressure injury on his right ischium (gluteal fold).
This failure could place 7 residents who had pressure injuries at risk for worsening of existing pressure injuries and developing new pressure injuries.
During an interview on 03/12/17 at 11:29 a.m., LVN B said she was the charge nurse for Resident #2. She said she had not performed wound care on Resident #2 today (03/12/17) because she did not have time yet. She said the treatment nurse provided treatments Monday through Friday and the charge nurses provided the treatments on the weekends. She said the treatment nurse was responsible for weekly skin assessments.
During an interview on 03/12/17 at 1:48 p.m., Resident #2 said staff had not performed wound care on his 2 pressure injuries since Friday (03/10/17).
During an observation on 03/12/17 at 3:31 p.m., Resident #2’s dressings on his sacrum and left ischium pressure injuries were dated 03/10/17. LVN B removed the soiled, yellow stained dressings that smelled of infection. LVN B removed the soiled packing from Resident #2’s sacrum and left ischium wound beds. The packing was stained brownish red and smelled of rotten flesh. Resident #2 said his wounds smelled bad because his dressings were not changed for 2 days. Resident #2’s stage 4 left ischium pressure injury wound bed was bright red and measured 5 cm x 3.1 cm x 5 cm. Resident #2’s stage 4 sacral wound bed was bright red and measured 3.5 cm x 5.8 cm x 9.2 cm. Resident #2 had an undocumented new pressure injury on his right ischium (gluteal fold) that was covered by the old bandage. The right ischium stage 2 pressure injury was red in color and measured 0.7 cm by 0.3 cm.
During an interview on 03/12/17 at 5:11 p.m., LVN C said she worked 03/11/17 and documented that she performed wound care on Resident #2, but did not actually do the treatment.
During an interview on 03/12/17 at 5:22 p.m., LVN B said she documented that she performed wound care on Resident #2 prior to performing his wound care. She said she did not have enough time to do the treatment for [REDACTED].
During an interview on 03/12/17 at 5:30 p.m., the DON said Resident #2’s wound care should have been provided daily.
Personal Note from NHA – 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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