THE COURTYARDS AT FORT WORTH
Located: 8001 WESTERN HILLS BLVD, FORT WORTH, TX 76108
THE COURTYARDS AT FORT WORTH was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following:
Please note: The following highlighted quoted text is only a portion of the full report/survey. The full report/survey can be found here.
WARNING: THE FOLLOWING QUOTED TEXT CAN BE DISTURBING TO SOME READERS.
Immediately tell the resident, the resident’s doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident – Level of harm – Immediate jeopardy Residents Affected – Many
On 09/12/13 at 11:00 AM, Resident #1 was observed in her room, lying on her bed. She was in a fetal position and had severe contractures of her arms, legs, and hands. She had swollen, inflamed, red welts on all visible areas of her body. Small clusters of welts and individual welts were around her hairline, upper and lower extremities, neck, and upper shoulder blades, plus on her hands and feet. A cluster of welts was on her inner left thigh in an area approximately 6.0 to 8.0 inches in length and 3.0 to 4.0 inches in width. Observation by the surveyor on 09/12/13 at 11:30 AM revealed Resident #1 was covered with red welts, which appeared to be ant bites, except for her middle back, feeding tube area, vaginal area, and under her breasts. The red welts were too numerous to count. During the assessment, Resident #1 responded to verbal and physical stimulus by opening her eyes and frowning. On 09/12/13 at 11:00 AM, during the initial observation of Resident #1, a family member was present and identified the welts as fire ant bites. The family member stated the incident occurred on 09/01/13. The family member further stated he/she received a telephone call on 09/01/13 around 5:30 AM from a staff member informing him/her ants were found in the resident’s room and Resident #1, along with her bed, had been moved to another room. the family member indicated this was a repeat notification of the ants observed on 08/31/13. The family member stated he/she received another telephone call from the facility later that same morning from a different staff member informing him/her of ants in the resident’s room. The family member stated he/she became concerned and decided to check on the resident. The family member stated when he/she arrived, Resident #1 was in her room, in bed, and covered in ants. The family member stated he/she began yelling for help and several staff members came to help brush the ants off the resident. The family member revealed he/she had to insist Resident #1 be sent to the hospital, where she was informed by hospital staff the number of ant bites suffered by Resident #1 could have led to her death.
Continuing: Based on observation, interview and record review, the facility failed to immediately consult one (Resident #1) of four residents’ physician when there is a significant change in the resident’s physical status. When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: — conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. — provide Resident #1’s physician/NP with an accurate assessment of Resident #1’s status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. — notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours.
Continuing: She stated around 9:00 AM, she saw Resident #1’s family member enter the resident’s room and then heard the resident’s family member yelling for help. She stated when she arrived at Resident #1’s room, hundreds of ants were on Resident #1, as well as on her bed and under the resident.
Continuing: On 09/17/13 at 11:04 AM, during an interview with MA G, he confirmed he worked on 09/01/13. He stated he heard Resident #1’s family member call for help and went to assist. He stated Resident #1 was covered from head-to-toe in ants. He stated he focused on helping get the ants off her. He added there were too many ants to count.
Continuing: The confidential interviewee (CI) stated he/she was present when Resident #1’s family member arrived at the facility around 9:00 AM on 09/01/13, and called for help. The CI removed Resident #1’s brief during the incident and could tell Resident #1 had not been provided incontinent care for a significant amount of time due to the wetness of the brief and pad, and the feeding residue on the pad (however, this was not confirmed). The CI believed the level of wetness and amount of feeding residue indicated Resident #1’s sheets had not been changed the night before when the ants where initially found in the resident’s bed. The CI stated Resident #1’s brief was filled with ants, and there were hundreds of ants on the resident, including when LVN F was in the room. The CI described Resident #1 as being covered in bites. The CI stated when Resident #1 returned from the hospital, she had to sit in her wheelchair for approximately an hour to an hour and a half because her bed, which had a new mattress, was not ready.
Continuing: The NP stated she had recently had problems getting accurate reports from staff at the facility. She stated staff were not reporting the full extent of situations and were not prepared with information. On 09/12/13 at 12:30 PM, during an interview with Resident #1’s physician, he stated the red welts observed by the surveyors were ant bites. He stated if he had seen the ant bites immediately after the incident, he would have sent her to the hospital. The physician stated he did not initially handle the incident, but the information his office received about the incident did not relay the seriousness of the incident. The physician stated the worst case scenario would have been Resident #1 experiencing anaphylactic shock. A secondary concern was a massive infection. The physician stated Resident #1 could experience scarring in the areas of the ant bites, and added that it could take up to another month for the bites to heal, and stated, There had to be hundreds of ants to have caused the extent of (Resident #1’s) injuries.
Continuing: The Post-Investigation action section reflected facility staff had been monitoring for ants in the facility since 08/28/13, due to ants found in two rooms.
Be administered in an acceptable way that maintains the well-being of each resident
Level of harm – Immediate jeopardy Residents Affected – Many
1) The Administrator failed to implement the facility’s Abuse (and Neglect) Policy when the Administrator failed to provide oversight of an investigation conducted by the DON. This resulted in a failure to identify the DON’s inadequate investigation of an incident of neglect. 2) The Administrator failed to ensure the nursing facility was physically maintained in a manner to protect the health and safety of residents and ensured the facility had an effective pest control program. 3) The DON failed to complete a thorough investigation and thus failed to identify training needs of LVN F. The DON conducted the investigation regarding Resident #1 sustaining multiple ant bites, but failed to identify the following: When Resident #1 was found with fire ants everywhere on her body and was being bitten, LVN F failed to: — conduct a head-to-toe assessment to determine with accuracy the number of fire ant bites she sustained, assessing for an allergic reaction and pain. — provide Resident #1’s physician/NP with an accurate assessment of Resident #1’s status and allowing the physician/NP to respond appropriately with orders to send her to the hospital. — notify the physician/NP Resident #1 was sent to the ER and when the resident returned from the ER with new orders until the resident had been back in the facility for over two hours.
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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