KATY, TX – LEGEND OAKS HEALTH AND REHABILITATION – KATY

Based on interview, and record review, the facility failed to ensure nurse competency in skills and techniques necessary to care for resident who sustained fall with bleeding laceration to forehead for one of one nurse ( LVN #1) reviewed for nursing services , in that : LVN #1 inaccurately assessed Resident #1’s laceration to her forehead after an unwitnessed fall. LVN #1inaccirately informed the NP that Resident #1 sustained a skin tear instead of a laceration . Resident #1’s laceration bleed for approximately 14 hours before LVN#1 consulted her physician for further interventions and treatment. Resident #1 required staples to close her laceration and stop bleeding after her transfer to ER and was life-flighted to a second local hospital after being diagnosed with [REDACTED].These failures affected one resident who had delayed intervention to stop her bleeding and placed her at risk of complication and decline in health.In an interview with the facility’s DON on 4/25/19 at 9:30 a.m., she stated she was very surprised when she saw Resident #1 after she returned from the hospital on [DATE]. She did not know how serious the resident’s injury was until she observed her with staples. She said LVN #1 described the laceration as a small skin tear and he had since been reprimanded. The DON said LVN #1 called her on 4/15/19 at 5 a.m. and said the skin tear was bleeding really bad because Resident #1 kept pulling on the dressing. The DON said it was really bleeding because it was a deep laceration and she realized that once the resident returned from the hospital.