LOCATED: 1501 W 29TH ST, TYLER, TX 75702
THE MELROSE 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 interview and record review, the facility failed to ensure necessary care and services were provided to prevent the development of pressure ulcers and necessary treatment and services were provided to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 3 residents reviewed for pressure ulcers. (Resident #1)
Resident #1 developed 4 facility acquired avoidable pressure ulcers. The facility did not provide appropriate and accurate assessments of the pressure ulcers, did not implement new interventions to prevent the development of and worsening of the pressure ulcers, and did not request a dietary follow up when the resident developed new pressure ulcers and the existing pressure ulcers worsened. The facility did not notify the physician at least 2 weeks after the resident’s pressure ulcers worsened in appearance and developed a foul odor. Resident #1 was admitted to the hospital due to gangrene in his pressure ulcers and osteo [DIAGNOSES REDACTED] (infection in the bones) that required surgical intervention, and long term intravenous (IV) antibiotic therapy.
These failures contributed to the development and worsening of 4 new pressure ulcers for Resident #1.
During an interview on 7/28/15 at 1:50 p.m., the DON said Resident #1 did not have a culture of his wound and was not on any antibiotics. The DON said on 6/23/15 he called the physician to get an order for [REDACTED]. He said until 7/21/15, he did not assess Resident #1’s pressure ulcers and did not know they were not healing. The DON said on 7/21/15 he was walking down the hall and smelled a foul odor coming from Resident #1’s room. He said at that time he saw the resident’s pressure ulcers and was upset by how bad they looked and smelled. The DON said he was disappointed in his staff due to the miserable state of Resident #1’s pressure ulcers. The DON said he called the NP and talked to her about getting an appointment at the wound clinic. He said there was a mix up with the dates, and Resident #1 was not seen at the wound clinic until 7/24/15. He said when Resident #1 was sent to the wound clinic, they wanted him sent to the hospital. The DON said he was not aware Resident #1 had four pressure ulcers when he left the facility and he was not aware when the fourth pressure ulcer developed. He said he was not aware the resident’s pressure ulcers had an odor since at least 7/6/15. He said he was not aware the area on his ischium (buttock) worsened to an unstageable pressure ulcer. The DON said he had not seen the nursing documentation of the resident’s pressure ulcers. He said the physician had not seen Resident #1’s pressure ulcers and they only called to get a consult for the wound clinic. The DON said the Weekly Pressure Ulcer Progress report was given to him weekly for notification of pressure ulcer healing. He said he was not aware Resident #1 had two unstageable pressure ulcers. The DON said he must not have reviewed the documentation closely. He said the last time he saw Resident #1’s pressure ulcers was 6/23/15. He said he was under the impression the resident’s pressure ulcers were healing.
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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