AFTON OAKS NURSING CENTER

LOCATED: 7514 KINGSLEY ST, HOUSTON, TX 77087

AFTON OAKS NURSING CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT

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

Based on observation , interview, and record review the facility failed to ensure 2 of 18 residents ( CR #1 and Resident #15) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that:

–CR#1 was not provided with catheter assessment and care from admission on [DATE] through discharge on [DATE] to prevent and then treat injury to his penis. His penis was split from the meatus down the shaft to the scrotum.

–Resident #15 had a significant change in condition on [DATE] that was not treated emergently resulting in delayed transportation, intervention, and treatment. He later died in the hospital on [DATE].

An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan.

–the patient was previously admitted in the hospital in July and was discharged after a two-week stay to nursing home with a Foley catheter

–Foley catheter presumed to be in place for likely [MEDICAL CONDITION] and there was no records found to document whether Foley catheter has been changed or not at the nursing home.

These failures affected 1 hospitalized and 1 current resident and placed 11 additional residents in the facility with an indwelling catheter at risk of injury, harm, delayed medical treatment intervention, and possible hospitalization or death.

Record review of CR#1’s clinical record revealed no documentation of follow up care or physician notification.

During an interview on [DATE] at 3:23 p.m. with the House Supervisor at the local hospital, she said her concern was that upon admission, CR #1’s Foley catheter was dirty, his penis was filleted, it was open and he (Resident # 1) was septic.

Record review of CR #1’s medical records from the the local hospital obtained on [DATE] revealed he was admitted to the emergency room of the hospital on [DATE] at 13:22 p.m. and upon nursing assessment, it was noted, .Foley in place extremely dirty with sediments all along tube walls, patient’s penis is split open from the bottom along the shaft. Urine dark brown It was also documented that CR #1 had [MEDICAL CONDITION] +2 to Right upper arm, right elbow, right forearm, left midcalf, left ankle, left upper arm, left elbow, left forearm, right midcalf and right ankle.

Record review of the Physician’s Progress Notes from the local hospital dated [DATE] at 9:55 p.m. revealed assessment and plan as follows:

–Sepsis secondary to healthcare-associated pneumonia and urinary tract infection secondary to [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) and [MEDICATION NAME].Urologist consult report from the local hospital dated [DATE] revealed as follows: –the patient noted on a thorough exam by ICU to have an indwelling Foley catheter for unknown reasons and found to have significant traumatic [DIAGNOSES REDACTED] from the Foley catheter.

Observation and interview of CR #1 in his room at the local hospital on [DATE] at 10:59 a.m. with the hospital nurse and social worker present revealed he was alert and oriented to person and place. His right hand was swollen. He answered questions appropriately and coherently. CR #1 said, I will be [AGE] years old and never had something like this happen like this, someone cut it-someone cut it completely open down the shaft . He added the service he received at Afton Oaks was not good. He said, It looks like someone didn’t like me, for some reason but I hadn’t did anything to anyone, I don’t want to go back there, my family member will take me home to (name of home State). CR #1 was in Isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his hospital nurse, she said it did not look like his catheter had been taken care of. She said there were old wounds to the front and lateral shaft. She said there was a large laceration on his penis draining pus and the meatus was sliced open, not healed, and with a pink bed to it.

Personal Note from NHA–Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.