BROOKHOLLOW HEIGHTS TRANSITIONAL CARE CENTER
LOCATED: 1737 N LOOP W, HOUSTON, TX 77008
BROOKHOLLOW HEIGHTS TRANSITIONAL 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 –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that residents who entered the facility without pressure ulcers did not develop pressure ulcers and residents with pressure ulcers received treatment and services to promote healing for 7 of 10 residents reviewed for pressure sores. (Residents # 1, 11, 14, 26, 5, 3, and #25)
-The Wound Treatment Nurse was unable to accurately describe, stage and measure pressure sores for Residents # 1, 11, 14, 26, 5, 3, and 25. – Resident #1 ‘ s Stage IV sacral pressure ulcer was not staged and measured correctly by the Wound Treatment Nurse. The resident received the incorrect treatment for [REDACTED]. The pressure ulcer increased in size on 03/11/15 and again on 03/18/15. – Resident #1 developed a Stage II pressure ulcer on his left ankle that was not identified by the facility until 03/26/15. The wound was covered with a dry dressing dated 3/24/15. The physician was not notified until 3/26/15 of the new Stage II on the left ankle. – Resident #1 unstageable wound to the left hip was not documented on the wound reports and there was no physician order for [REDACTED].>-The Wound care nurse applied the incorrect treatment to Resident #1 ‘ s left shoulder wound. – Resident #11, who entered the facility without pressure sores on 2/18/15, developed multiple unstageable wounds on 3/9/15.
On 03/23/15 he developed a Stage II pressure ulcer to left buttock. Pressure relieving devices for the wheelchair were not applied. Resident #11 was not being re-positioned, heels were not being offloaded and Prevalon boots were not applied as per plan of care. The depth of the wound was not measured. – Resident #14 developed a Stage II right buttock pressure ulcer on 1/20/2015. The pressure ulcer increased in size and worsened to a Stage III by 2/18/2015. The depth of the wound was not measured.
-Resident # 14 was not being turned and re-positioned as per care plan.
-Resident # 14 did not have pressure relieving devices in her bed or chair for a Stage III wound on her buttock.
-Resident #5 who had a Stage IV pressure sore to his bilateral buttocks and multiple wounds on his right leg, was not turned and re-positioned as per care plan.
-Resident #3 developed pressure sores on the left ankle. Orders to float his feet were not being followed. The wounds increased in size. The depth of the wound was not measured.
-Resident # 26 wounds were not measured correctly by the Wound Treatment Nurse. Resident #26’s sacral wound deteriorated to a Stage IV with tunneling by 03/16/15.
– Resident #25 who was assessed by the facility to be at low risk for developing pressure ulcers and entered the facility with no pressure ulcers on 12/2/14, developed multiple avoidable wounds to include a Stage IV to the sacrum, a Stage III to right malleolus, unstageable wounds to bilateral feet and other wounds on her hips and back. Skin assessments did not accurately reflect her skin breakdown. The depth of the wounds was not measured. An IJ was identified on 3/26/15. While the IJ was lowered on 3/31/15, the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness.
These failures affected 7 residents and placed the other 10 residents with pressure sores at risk of further neglect, deterioration of ulcers, pain, infection, developing more ulcers and a decline in their quality of life.
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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