FORT WORTH WELLNESS & REHABILITATION – FORT WORTH, TX

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

Based on record review and interview, the facility failed to ensure nursing staff provided care including, but not limited to assessing, evaluating and responding to resident needs for one (Resident #424) of 44 residents reviewed for staff competency. LVN I failed to provide appropriate assessment for resident #424 after he suffered a fall with head injury and pain on [DATE].

Resident #424 experienced pain, vomiting, and a hematoma after the fall and died on [DATE].

This failure could place residents at risk of not being assessed after an injury and could result in worsening injury and/or untimely death.

An interview with DON T (current facility DON) on [DATE] at 9:42 AM revealed she was not employed at the time of the incident with Resident #424, but she heard LVN I was terminated due to a resident falling and dying. The DON reported if a resident had a fall, the nurse was supposed to immediately assess the resident and complete neurological checks. The DON reported if the resident was being discharged, the nurse was supposed to try to convince them to stay and allow continued monitoring. If the resident refused to stay for monitoring, then the nurse was supposed to inform the doctor, contact Adult Protective Services, and the discharge would be against medical advice.

An interview on [DATE] at 11:10 AM with Relative #1, Resident #424’s family member, revealed Relative #2 arrived at the facility to transport the resident to a new facility. The resident complained about a headache and had a knot the size of a hand on the back of his head. The staff acted like they wanted to get the resident out of the facility more than anything else. The resident started vomiting after they got him in the car. At the new facility, the nurse assessed the resident and said they could not admit him and called 911. The resident was taken to the hospital, where it was determined he had a brain hemorrhage and the resident passed away the next day.