HUMBLE, TX – OAKMONT HEALTHCARE AND REHABILITATION CENTER OF HUMBLE

Based on observation, interview and record review, the facility failed to ensure the resident’s right to be free from neglect for 2 of 4 residents (CR #2 and Resident #1) reviewed for neglect, in that: -CR #2 was found on the floor and nursing failed to conduct a thorough assessment. CR #2’s STAT x-ray was delayed 6 hours, resulting in a left femur fracture. -Resident #1’s STAT x-ray was not completed timely. These failure affected one current resident and one discharged resident and placed 58 additional residents residing on the 100 hall at risk of not receiving goods and services necessary to avoid physical harm or pain.

Record review of nursing note, SBAR by LVN #4 for [DATE] at 3:30pm revealed at 1:10pm CR #2 was found on the floor in his room by a staff. He was assisted back to bed. He complained of pain to left hip.[MEDICATION NAME] given for pain, and patient instructed to stay in bed. Did not remove pants;  because of pain to left hip. A call was placed to hospice nurse at 1:30pm. On [DATE] at 2:06pm a return call by the physician; and new orders for a STAT x-ray to the left hip. At 2:15pm, [MEDICATION NAME] was given and CR #2 was resting with family at bedside. Record review of nursing facility investigation summary undated and unsigned, revealed when CR #2 was in bed, LVN #4 initiated a head to toe assessment but unable to complete full assessment to left lower limb due to CR #2’s complaints of pain to hip area. After completion of assessment, CR #2 was medicated for pain accordingly. STAT X-ray ordered. Hospice nurse arrived around 4:00pm and had attempted to call local mobile imaging company multiple times for an x-ray. At 7:22pm, CR #2’s family member requested he be sent to the hospital. At approximately 7:30pm orders were obtained to send CR #2 to the hospital for evaluation and treatment. When EMS arrived, CR #2’s pants were removed and his left hip appeared deformed. CR #2 left the nursing facility on [DATE] at 7:50pm.