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While Pressure Sores on Left Heal and Buttock Worsened, Facility Failed to Assess Wound and Notify Physician; Resulting in 40 Days of Treatment Without Orders

FORTRESS NURSING AND REHABILITATION LP

LOCATED: 1105 ROCK PRAIRIE RD., COLLEGE STATION, TX 77845

FORTRESS 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 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 three (3) of 14 Residents (Resident #4, #9, and #12) reviewed for pressure sores received necessary treatment and services to promote healing, accurately assess and stage, and once developed, failed to ensure necessary treatment and services to promote healing. A.) Resident #4 was admitted to the facility on [DATE] with a Stage II sacral and left heel ulcer per hospital discharge records. The facility did not assess, properly measure, stage or implement/clarify physician ordered treatments to Resident #4’s left heel pressure sores or sacral ulcers resulting in worsening of Resident #4’s left heel and sacral pressure sores. The facility failed to address Resident #4’s pain associated with wound care treatment. Resident #4 ‘ s left heel became infected and was cultured on 10/08/13 with results received on 10/11/13 not conveyed to the physician until 10/14/13, an additional 3 days, resulting in a delay of antibiotic treatment. Resident #4 ‘ s sacral ulcer treatment order ended on 08/14/13 and was not clarified until 10/01/13 resulting in 40 days of treatment without orders while the wound worsened from a stage II to multiple stage III wounds. Resident #4’s physician was not notified of the worsening sacral ulcers until Surveyors brought it to his attention on 10/23/13. Resident #4 was ordered to have a consult with a wound care specialist on 8/07/13; Resident #4 had not seen the wound care specialist as of 10/23/13.

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores

Continuing: Based on observation, interview and record review the facility failed to ensure three (3) of 14 Residents (Resident #4, #9, and #12) reviewed for pressure sores received necessary treatment and services to promote healing, accurately assess and stage, and once developed, failed to ensure necessary treatment and services to promote healing. A.) Resident #4 was admitted to the facility on [DATE] with a Stage II sacral and left heel ulcer per hospital discharge records. The facility did not assess, properly measure, stage or implement/clarify physician ordered treatments to Resident #4’s left heel pressure sores or sacral ulcers resulting in worsening of Resident #4’s left heel and sacral pressure sores. The facility failed to address Resident #4’s pain associated with wound care treatment. Resident #4 ‘ s left heel became infected and was cultured on 10/08/13 with results received on 10/11/13 not conveyed to the physician until 10/14/13, an additional 3 days, resulting in a delay of antibiotic treatment. Resident #4 ‘ s sacral ulcer treatment order ended on 08/14/13 and was not clarified until 10/01/13 resulting in 40 days of treatment without orders while the wound worsened from a stage II to multiple stage III wounds. Resident #4 ‘ s physician was not notified of the worsening sacral ulcers until Surveyors brought it to his attention on 10/23/13. Resident #4 was ordered to have a consult with a wound care specialist on 8/07/13, Resident #4 had not seen the wound care specialist as of 10/23/13.

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

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