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NAVASOTA, TEXAS – RESIDENT SUFFERS BEDSORE DOWN TO BONE; EXTREME PAIN IGNORED BY STAFF

NAVASOTA NURSING AND REHABILITATION

LOCATED: 1405 EAST WASHINGTON, NAVASOTA, TX 77868

NAVASOTA 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 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**
Review of Resident #13’s Nursing Documentation Record reflected Resident #13 on 07/11/2013 at 08:10 AM Resident #13 staff and nurse in room to do dressing change and resident agitated and yelling and hitting at staff, states he wants out of here. Observation on 07/11/2013 at 7:00 PM revealed LVN C providing treatment to Resident # 13’s Stage IV pressure sore (Stage IV-Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling ). That measured approximately 6.0 cm x 4.0 cm x 2.0 cm (approximation made by surveyor) no dressing was present to be removed, wound bed of red granulation tissue was noted at the posterior aspect of wound from 6 o’clock to 9 o’ clock the rest of the wound bed was covered in yellow slough and eschar. Resident #13’s sacral Stage IV pressure sore had a pervasive odor. LVN C then took one (1) of the stacks of 4×4’s and placed them in Resident #13’s sacral pressure sore and cleaned using a twisting motion. Resident #13 began making incoherent verbalizations, becoming increased as LVN C cleaned pressure sore using the twisting motion. LVN C then cleansed Resident #13’s sacral pressure sore again using the twisting motion with a new stack of 4×4 gauze. Resident #13’s entire body began to shake and he had his right hand in a fist formation. Resident #13’s incoherent verbalizations increased in volume. Surveyor then asked Resident #13 if he was in pain. Resident #13 continued to shake and make incoherent verbalizations. LVN C did not stop cleaning the wound or address Resident #13. DON A did not address Resident #13 but continued to observe LVN C clean Resident #13’s sacral pressure sore. Resident # 13 continued with loud verbalization and shaking while LVN C repeated the cleaning, again using the twisting motion, LVN C then took hydrogel gauze and shoved it with force into Resident #13’s sacral pressure sore. Resident #13 made a loud verbalization, his entire body was shaking and he grabbed at DON A. DON A did not respond to Resident # 13’s grabbing, she continued to hold the resident in position and observed LVN C. LVN C then shoved another hydrogel gauze into Resident #13’s sacral pressure sore and covered area with a [MEDICATION NAME] dressing. In an interview on 07/11/2013 at 7:20 PM surveyor asked Resident #13 if he was hurting after wound care was complete. Resident #13 stated Yes I am hurting surveyor then asked Resident #13 where he was hurting and Resident #13 used his right arm to show surveyor his sacral area. In an interview on 07/ 3 at 7:30 PM LVN C stated when she cleaned Resident #13’s sacral pressure sore deeper Resident became more verbal. LVN C further stated she was not expecting Resident #13 to react that way. Surveyor then asked LVN C if she should have stopped the procedure when she noted Resident #13’s reaction. LVN C stated she should have stopped the procedure. LVN C stated she should have pre-medicated Resident #13 with pain medication prior to procedure but she was unsure what kind of medication Resident #13 had for pain. In an interview on 07/11/2013 at 8:00 PM DON A stated that she would notify Resident #13’s physician regarding Resident #13’s pain since he only had Tylenol ordered PRN for pain. DON A stated that LVN C should have stopped the treatment to Resident #13’s sacral pressure sore the resident was in pain. DON A further stated that Resident #13 should have been assessed for pain prior to procedure and during procedure for signs of pain. DON A stated she knew LVN C was in a hurry to leave so she did not stop the procedure. Surveyor then asked DON A if a resident with a pressure sore that size would be in pain all time and DON A stated they would be in continuous pain and that Resident #13’s pain was not addressed because she missed it.

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

You can make a difference even if your loved one has already passed away.

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