FORT STOCKTON LIVING & REHABILITATION
LOCATED: 501 N SYCAMORE, FORT STOCKTON, TX 79735
FORT STOCKTON LIVING & 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 GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure 5 of 6 residents (Resident #1, #3,#4, #17 and #18) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to:
Perform skin assessments every shift per Resident #1’s care plan dated 2/19/17 and to identify Resident #1 suspected deep tissue injury (SDTI)
Accurately assess Resident #3 for pressure injuries. The assessments indicated he was a moderate risk for pressure injuries after he already had one. Resident #3 was assessed with [REDACTED].
Accurately assess Resident #4 for pressure injuries. The assessments indicated he was at moderate risk for pressure injuries after he already had one. Resident #4 was assessed with [REDACTED].
Accurately assess Resident ##17 for pressure injuries. The assessments indicated she was at risk for pressure injuries after she already had one.
Accurately assess Resident #18 for pressure injuries. The assessments indicated he was at risk for pressure injuries after he already had one.
This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/6/17. While the IJ was lowered on 4/11/17 the facility remained out of compliance at a level of actual harm with a scope identified as a pattern because they had not had time to monitor for effectiveness.
This deficient practice placed 13 residents at risk of not receiving wound care treatments, skin assessments or interventions and put them at risk of life threatening complications.
During an interview on 4/6/17 at 1:58 p.m. the Treatment Nurse said she had been the treatment nurse off and on for several years. She said this time she had been the treatment nurse for over a year. She said she got pulled treatments to do other jobs because of staffing issues. She said her Corporate Office had said she was not to be pulled. She said last week she had to go to wound care Monday and Friday and then Wednesday she was pulled to work the floor which gave her 2 days to do treatments and skin assessments. She said this week (4/3/17 – 4/7/17) she was pulled to the floor on 4/3 to be the medication nurse and 4/04/17 she had to transport a resident to wound care. She said she had talked to the DON about sending one resident with just two aides to wound care. She said she physically counted the number of wounds in the building when she did the skin report and was very aware of the number of residents with pressure injuries. She said the numbers seem up there. She said the aides were usually very good about reporting changes to her. The Treatment Nurse said she tried to do skin assessments on one hall a day.
During an interview on 4/06/17 at 2:55 p.m. the Administrator said she was not informed of Resident #1’s pressure injury until the next day. She said unstageable was the most explanation she got. The Administrator was informed that no full body assessment was completed until after 9 a.m. the day after the unstageable was discovered on Resident #1. The Administrator acknowledged the system had broken down. She said it appeared the problem started with the Hospice aides and not telling any of the staff. She said once the Treatment Nurse was notified she should have done a full assessment. The Administrator said the facility CNA’s provided incontinent care and as needed bed baths. She said they provided care like repositioning and putting on the heel protectors that everyone kicks off. She said as they were repositioning Resident #1 she would think they would see the unstageable pressure injury.
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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