DALLAS, TX – BRENTWOOD PLACE ONE

Based on observation, interview and record review, the facility failed to keep residents free from neglect for six (Residents #1, #2, #3, #4, #5 and #6) of eight residents reviewed for neglect.
The facility failed to provide staff with training on the assessment and treatment of [REDACTED]. These failures were evidenced by:

1. The nursing staff failed to assess Resident #1’s pressure ulcer on admission and failed to assess the condition of Resident #1’s pressure ulcer from 08/03/18 until 08/30/18 for a total of 27 days. On 09/06/18, Resident #1 was transferred to the hospital where she was found to have five unstageable pressure ulcers and a DTI that had not been identified by the facility.

2. The nursing staff failed to provide Resident #2 with physician-ordered pressure ulcer treatment for [REDACTED].

3. The facility failed to implement its Skin Integrity Monitoring System by failing to consistently perform weekly skin assessments for the presence of pressure ulcers and failing to conduct quarterly screening for the risk of pressure ulcer development for Residents #1, #2, #3, #4, #5, and #6.

4. The facility failed to ensure licensed nursing staff had the knowledge and skill to provide necessary care and services related to the identification, assessment, documentation, and treatment of [REDACTED].#1, #2, #3, #4, #5, and #6.

An Immediate Jeopardy (IJ) was identified on 09/11/18. While the IJ was removed on 09/17/18, the facility remained out of compliance at isolated with actual harm that was not immediate jeopardy due to the facility’s need to monitor the effectiveness of the Plan Removal.
These failures affected 6 residents with pressure ulcers and placed 7 residents with pressure ulcers and 35 residents receiving preventive skin care at risk for developing new pressure ulcers, pain, deterioration in existing pressure ulcers, infection and even hospitalization .