HOUSTON, TX – SOLERA AT WEST HOUSTON

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of 19 residents (CR #1) reviewed for quality of care, the facility failed to; Monitor CR #1, who had [DIAGNOSES REDACTED].

Develop and communicate to staff on the baseline care plan interventions focusing on care procedures for CR #1 who was a diabetic with an end stage [MEDICAL CONDITION], was on isolation for shingles , had limited communication capability and was totally dependent on staff for all medical and ADL care.

Assess CR#1’s blood sugar when performing cardio [MEDICAL CONDITION] resuscitation (CPR). CR#1 received long acting insulin the night before and had no food for over 12 hours when found unresponsive at 9 am. CR #1’s blood sugar was not checked to rule out diabetic coma.

Provide timely blood sugar checks and medications. CR#1 had ordered blood sugar at 6:30am which was not documented as being completed and 8am medications which were not documented as administered by 9am when the resident was found unresponsive. CR #1 was pronounced dead on scene by Emergency Medical Services on [DATE] at 9:20AM with no resuscitation attempted due to obvious signs of death of Rigor Mortis.

Develop a system and communicate this system to nursing staff to ensure nursing staff identified insulin dependent diabetic residents requiring prompt meal assistance to be provided to them.

An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility continued to train staff and monitor the effectiveness of the Plan of Removal.

These failures affected one resident who died in the facility at an unknown time.

Interview on [DATE] at 5:00PM, CR#1’s family member said the facility called her around 9:30AM and told her CR #1 had passed at 9:20AM. She said the facility did not tell her what happened, and she had concerns about how she passed away. The family said they were told by a nurse in the hallway that it was a therapist who found her unresponsive. The family said CR #1 was diabetic and should have had her blood sugar checked at 6:30AM, had her morning medications, and had her breakfast before the time she was found. The family wanted to know what her blood sugar reading was that morning and what condition she was in that morning before she became unresponsive. The family was very upset and said she felt the facility did not properly care for CR #1 and said she was fine the day before when she visited. The family also said the resident had [MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays at 11:00AM and the [MEDICAL TREATMENT] center had called her saying the resident was late to her appointment on [DATE] and [DATE]. The family was concerned the facility was not getting the resident up and ready to make it to her [MEDICAL TREATMENT] appointments on time.