DESOTO,TX- WILLIAMSBURG VILLAGE HEALTHCARE CAMPUS

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices to meet each resident’s physical mental and psychosocial needs for one (Resident #6) of seven residents reviewed for quality of care.

The facility failed to ensure Resident # 6 received medications according to physician orders for pain management when the resident experienced a fall with injury that resulted in a fracture to the left hip. Resident # 6 was in pain for three days before being sent to the hospital. This failure placed residents at risk of unrelieved pain and discomfort.

An Immediate Jeopardy was determined to have existed from 11/04/22 through 11/07/22. The IJ was removed on 11/08/22 because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. The facility Administrator was provided the IJ Template on 01/12/23 at 9:52 AM.

Findings included:
Review of Resident # 6’s Face Sheet dated 12/23/2022 revealed a 79-yr-old female who admitted to the facility on [DATE] and discharged on [DATE]. Resident # 6’s diagnoses included cerebral infarction, unspecified injury of head, diabetes mellitus, and central pain syndrome.

Review of Resident # 6’s Progress Note dated 11/04/22 written by LVN S reflected, Resident was in her room and was pushed down by another resident, resident fell on her left hip and exhibited signs of pain called dr to report change of condition, ordered x- ray to have left hip examined.

Review of Resident # 6’s NP Note dated 11/4/22 reflected, The patient is seen for a periodic follow-up visit. She is seen sleeping in her bed recently, easily awoke with verbal stimuli. She is very confused secondary to dementia but denies any acute problem at the present time. Later on I was notified over the phone while I am driving that the patient is complaint pain on the left hip area. She was pushed by another confused patient and the patient fell . Ordered left hip x ray and instructed to treat the pain with the pain medication. Nurse will notify provider if symptoms get worst. She is generally agreeable to care routine and easily redirected.

Review of the Incident Report dated 11/04/22 reflected Resident # 6 was involved in a witnessed altercation with a fall and had pain upon movement at a level four on a scale of 1-10.

Review of Resident #6’s Physician’s Orders reflected the only pain ordered for Resident # 6 was 500 mg of Naproxen. One tablet was to be given twice per day as needed for Mild pain on a scale of 1-3. This Naproxen medication was to be given with food and the diagnosis for this medication was central pain syndrome.

Review of the Medication Administration Record (MAR) in the electronic medical record on 01/12/23 for Resident #6 revealed she had pain at a level six to her left hip on 11/06/22 in the evening. The MAR also revealed Naproxen was not administered to Resident # 6 from 11/4/22 through 11/7/22. The MAR reflected that no pain medication was given to Resident #6 during that time frame.

Review of Resident # 6’s Progress Note dated 11/06/22 at 2:13 PM written by LVN S reflected, resident having difficultly standing on left hip has mild edema of left leg, notified NP, ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out.

Review of Resident # 6’s Progress Note dated 11/07/22 at 1:55 PM written by LVNS on reflected, resident having difficultly standing on left hip has mild edema of left leg, notified Dr ordered x ray STAT per NP if not completed in 3-4hr span was advised to send resident out , x- ray not done notified [agency name] ambulance to transport resident to hospital for x- ray and further care, notified family/ unit manager of change of condition, ambulance scheduled for 3:30pm to transport.

Review of the Witness Statement dated 11/08/22 reflected LVN S was notified on 11/04/22 that Resident # 6 was pushed by another resident and fell . LVN S found resident on her left side and completed an assessment. The written statement indicated, Assessment noted pain to left hip with no visible injuries. New orders received and inputted for x-ray to left hip. On 11/6/22 x-ray had not been performed, I was notified by aide that resident continued with decrease in mobility and signs of pain upon assessment left hip noted with minimal edema, I notified NP and was given orders to reorder Xray as STAT, I inputted the orders. Upon arrival on 11/7/22 X-rays had not been performed I notified the NP and received orders to send to ER for further evaluation, resident was sent via non-emergency transportation.

Review of the Witness Statement dated 11/08/22 reflected CNA AF witnessed the incident with Resident # 6 and notified LVN S immediately. CNA AF’s written statement indicated, Resident #6, continued to have symptoms of pain to her left hip and decreased mobility on 11/5/22 and 11/6/22, I notified the charge nurse and resident remained in bed on those dates.

Interview on 12/22/22 at 10:20 AM with LVN S revealed the general procedure if a resident had a witnessed fall, the nurse was to complete a full assessment to include skin and pain evaluations, vital signs, then inform the unit manager, the Administrator, the family and the doctor. In a later interview on 01/12/23 at 10:09 AM LVN S stated she gave Resident #6 pain medication after she fell on [DATE]. LVN S stated Resident # 6 typically wanted to stay in bed, but once staff got her up, she would get up and walk around. LVN S said she would personally walk the halls with Resident # 6 but would keep a wheelchair close by in case the resident got weak and needed to sit down. A later phone Interview on 01/12/23 at 3:01 PM with LVN S revealed she attributed not documenting the administration of the Naproxen to the adrenaline of the whole issue

Interview on 01/12/23 at 11:27 AM with CNA AF stated Resident # 6 was able to walk to the dining room on 11/4/22 after the fall with no problem after LVN S did all the assessments. CNA AF stated that on 11/5/22 Resident # 6 was no longer getting up, could not walk and was screaming of pain. CNA AF stated that Resident #6 was able to walk before the fall, although if the staff would let her, she would lay in bed all day.

In an interview on 01/12/23 at 12:45 PM the ADON stated she checked their system and did not find any documentation of pain medication given to Resident #6, however she spoke with LVN S who stated she gave Resident # 6 Naproxen.

Interview on 12/22/22 at 3:38 PM with Resident # 6’s Primary Contact listed on Face Sheet stated Resident #6 was diagnosed with left hip fracture and had surgery where her socket was removed.

The primary contact stated the resident was still in pain and was at another (different) facility and had to go on hospice after the surgery. The Primary contact stated Resident #6 used to walk and now she stayed in a fetal position in bed because she was in too much pain.

Interview on 01/12/23 at 5:30 PM DON stated if a Resident has had a fall, their pain should be treated. DON stated that if pain medication was not adequate, the staff should contact the doctor to get something stronger so that the resident is not in distress. DON stated If the stronger medication does not help, the resident should be sent to the hospital. DON also stated that in the nursing world if it was not documented, it was not done.