OVERTON HEALTHCARE CENTER
LOCATED: 1110 HWY 135 S, OVERTON, TX 75684
OVERTON HEALTHCARE 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 PROVIDE SUPERVISION TO PREVENT HOT BEVERAGE BURNS
Level of harm – Actual Harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide supervision to prevent hot beverage burns for 1 of 5 residents reviewed for accidents. (Resident #2) Resident #2 was not assessed for his ability to manage hot beverages. Resident #2 sustained blisters to his legs while serving himself coffee. This failure could place 12 residents on the men ‘ s secure unit at risk for injury. Findings included: Physician orders [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had severely impaired cognitive skills for daily decision making, was unsteady, used a wheelchair and walker for mobility, and required supervision with setup help with eating. A comprehensive care plan revised 03/19/14 indicated Resident #2 was at risk for injury from wandering in an unsafe environment. Approaches included monitoring every hour and as needed to keep the resident ‘ s environment safe from possible hazards. The care plan indicated the resident required assistance with ADLs. The clinical record for Resident #2 did not have an evaluation to determine his ability to manage hot beverages. An Incident Report dated 04/25/14 indicated Resident #2 was assessed in his room with five blisters on his legs, three to both of his lower legs and one on each thigh. Resident #2 stated coffee when asked what happened. A Provider Investigation Report dated 4/29/14 indicated Resident #2 was discharged on [DATE]. A Provider Investigation Report dated 5/6/14 indicated Resident #2 received blisters to the right and left lower leg. The investigation summary indicated dietary staff saw Resident #2 getting coffee all day in a large plastic cup. During an interview on 05/14/14 at 2:00 p.m., LVN C said she assessed Resident #2 on 4/25/14 and discovered blisters on his legs. She said she was unsure of what occurred, but Resident #2 said coffee when she asked him how the blisters occurred. During an interview on 05/14/14 at 8:30 a.m., CNA A, said she worked the men ‘ s secure unit where Resident #2 resided. She said she was not aware Resident #2 spilled coffee on himself. She said residents continued to freely serve themselves coffee. She said 12 residents resided on the unit. CNA A said they all exhibit behaviors and required assistance with activities of daily living. She said the unit was staffed with one CNA. CNA A said one CNA could not provide the required care, supervision and monitor residents for behaviors. During an interview on 05/14/14 at 1:00 p.m., CNA B said he worked on the men ‘ s secure unit where Resident #2 resided. He said she was not aware Resident #2 spilled coffee on himself or if any preventative measures put into place. He said the unit had 12 residents who exhibited behaviors and required assistance with activities of daily living. He said the unit was staffed with one CNA. CNA B said one CNA could not provide the required care, supervision and monitor residents for behaviors. During interviews on 05/14/14 at 1:35 p.m., LVN D said she was assigned to the men ‘ s secure unit where Resident #2 resided. She said she was not aware Resident #2 spilled coffee on himself until today and was unsure if preventative measures were implemented.
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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