TREEMONT HEALTHCARE AND REHABILITATION CENTER
LOCATED: 5550 HARVEST HILL ROAD, DALLAS, TX 75230

TREEMONT HEALTHCARE AND REHABILITATION 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.

LINK TO DATE OF CORRECTION:
http://facilityquality.dads.state.tx.us/qrs/public/qrs.do?page=qrsCitationDetail&mode=P&lang=en&provno=000114&cgName=nh

FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT

LEVEL OF HARM –IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain physical, well-being, in accordance with the comprehensive assessment and plan of care for one (Resident # 19) of 5 residents whose clinical records was reviewed for diabetes.

1. LVN C failed to follow physician’s orders [REDACTED]. The blood sugar was low with a reading of 49 mg/dl -normal levels (70mg/dl to 110mg/dl). The physician orders [REDACTED]. The physician’s standing orders (orders given by the physician for all diabetic residents who may experience high or low blood sugars) reflected, for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular) and call MD (Medical Doctor). For reading between, [DATE] mg/dl, give orange juice and call the MD.

2. LVN C failed to consult the physician of the resident’s change in condition until after he became unresponsive approximately 1 ½ and hours after the resident’s blood sugar dropped and subsequently expired at that time.

3. The facility failed to ensure 5 of 5 current diabetic resident was thoroughly assessed, and treated as the physician directed. There is a potential for the 24 diabetic residents of the facility to be affected. An Immediate Jeopardy was identified on [DATE] at 11:31 AM. While the Immediate Jeopardy was removed on [DATE] at 10:33

PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm, that is not an immediate jeopardy, because staff were still being trained and the facility was monitoring the implementation of the Plan of Removal.

Findings included:

Resident #19’s Face Sheet dated [DATE], reflected the resident was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED].

The Departmental Notes dated [DATE] reflected Resident #19 was found unresponsive between 2:45 a.m. and 3:00 a.m. with a blood sugar of 95mg/dl. LVN C placed oxygen on Resident #19, but did not initiate CPR in the absence of a pulse. According to 911 operator the call for EMS (Emergency Medical Services) was received at 3:37 a.m., arrived at the facility at 3:44 a.m. The time of death was not in the report but EMS cleared the facility at 4:33 a.m. The cause of death was sudden death due to [MEDICAL CONDITION] according to the physician written statement on [DATE].

Resident #19’s MDS assessment, dated [DATE] two days after the resident expired reflected Resident #19 had short term memory problems, with moderately impaired decision making abilities. Resident #19 was able to make himself understood and he had the ability to understand others.

MDS assessment dated [DATE] reflected the following Diagnoses: [REDACTED]. Physician’s orders [REDACTED]. #19 was to receive the following treatment for [REDACTED].) The physician for Resident #19 also had Standing Physician order [REDACTED]. The current standing orders dated [DATE] reflected the following: SSI (Sliding Scale Insulin) for readings below 70 mg/dl give [MEDICATION NAME] 1 amp ([MEDICATION NAME]) IM (Intramuscular) and call MD (Medical Doctor). , [DATE] mg/dl Give Orange Juice and call the MD. These orders were provided by the regional nurse consultant as current on [DATE].

The Departmental Notes dated [DATE] at 7:36 a.m. reflected at approximately 2:00 a.m. Resident #19 reported he was hungry and the resident was given a snack of crackers and chocolate milk. CNA D noted the resident was diaphoretic (sweating). LVN C checked the resident’s blood sugar and it was 49mg/dl, LVN C gave orange juice for the low blood sugar instead of the ordered glucose tablets. LVN C did not administer glucose tablets, or the [MEDICATION NAME] by injection. In addition, LVN C failed to notify the physician of Resident #19’s low blood sugar of 49 mg/dl or any other blood sugar findings. The notes further reflected blood sugars were checked at 2:15 a.m. with a resulting blood sugar of 51 mg/dl and again at 2:30 a.m. with the results being 60mg/dl. The notes further reflected the resident was alert and oriented both times. The Departmental notes reflected between 2:45 a.m. and 3:00 a.m. Resident #19 was found unresponsive and blood sugar was 95mh/dl. The nurse checked the code status of the resident and noted he was a full code. The facility staff called emergency services (911) at that time, left message on the physician answering service. Upon assessment unable to get vital signs. When paramedics arrived they visualized the resident and assessed his pulse and stated the resident had expired.

On [DATE] the facility contacted 911 and according to 911 operator the call for EMS (Emergency Medical Services) on [DATE] was received at 3:37 a.m., EMS arrived at the facility at 3:44 a.m. The time of death was not in the report but EMS cleared the facility at 4:33 a.m.

The Medical Director in a hand written note dated [DATE] documented cause of death was sudden death due to [MEDICAL CONDITION].

On [DATE] at 6:37 p.m. during a telephone interview LVN C revealed Resident #19 was alert and oriented when his blood sugar was 49mg/dl and she gave him orange juice. LVN C revealed she checked the resident frequently and he was alert. An additional telephone interview with LVN C on 03 /, [DATE] at 2:06 p.m. LVN C she was asked why she did not follow the physician’s orders [REDACTED]. #19 was alert and she chose to give him orange juice because he was awake and alert. LVN C was then queried if she checked the physician orders [REDACTED]. LVN C was queried regarding Resident #19’s physician’s standing orders for low blood sugars and she revealed if (blood sugar was below 70mg/dl to give [MEDICATION NAME] IM). LVN C revealed the resident was awake. LVN C further stated it was very chaotic that night.

On [DATE] at 6:39 p.m. during a telephone interview, CNA D revealed Resident #19 told her he was hungry, after talking with LVN C, she got him a snack of crackers and chocolate milk. According to CNA D, the following events occurred with Resident #19: the resident spilled the milk and I went to clean him up and noticed he was diaphoretic (sweating) and told the nurse to come quick. The nurse checked his blood glucose several times and CNA D stated it was (50, 60, then 95). The resident went to sleep. Later, when I went to the resident’s room to empty his trash, I noticed he was breathing. Later the nurse went in and said he was unresponsive. The other nurse came and felt a carotid pulse. The nurses were about to start CPR when the paramedics came in.

On [DATE] review of personnel records for LVN C reflected her temporary Texas Nursing License expired on [DATE]. At approximately 3:00 p.m. The Administrator was asked about LVN C. The Administrator revealed LVN C had not worked in the facility since her license had expired. She did however work the week-end prior to [DATE].

In-services were conducted on [DATE] for LVN C regarding glucose monitoring, signs and symptoms of low blood sugars. Immediate Jeopardy was identified on [DATE].

The Administrator and Director of Nurses were identified of the Immediate Jeopardy on [DATE] at 11:31 a.m.

Internal Investigation Report dated [DATE] the facility initiated an investigation into the allegation of neglect of

Resident #19.

Interviews were conducted on [DATE] with involved nursing staff which included CNA D and LVN C.

Review of LVN C’s personnel file reflected her temporary Texas License expired on [DATE] and she no longer worked at the facility after her license expired.

The facility initiated re-education of the nursing staff in the care of diabetic residents. This education included defining diabetes, sign and symptoms of high blood sugar includes: blurred vision, drowsy, frequent urination, change in behavior, vomiting, weakness, and increased thirst. Low blood sugar the symptoms include: Confusion or exhaustion, not being able to concentrate, weakness, aggression or irritability, blurred vision, nausea, sweating and shakiness. In-Services were held on [DATE], [DATE] and [DATE] to educate the staff in how to treat a diabetic resident.

On [DATE] at 3:00p.m. an in-service was conducted on recognizing low blood sugars by the DON and 26 licensed nurses attended the training.

On0 [DATE] at 2:00 p.m. an in-service was given by the DON regarding diabetic care, which included a change in condition. Twenty- six licensed staff attended the meeting.

On [DATE] at 4:00p.m. an in-service was given by the DON regarding availability of glucose tablets. Twenty one licensed staff attended the training.

On [DATE] at 4:00p.m.an in-service was given by the DON regarding availability of glucose tablets, overview of diabetes and timely notification of the physician when a change in condition occurs. Eighteen licensed staff attended the training.

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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