PALOMINO PLACE
LOCATED: 3160 GUS THOMASSON ROAD, MESQUITE, TX 75150

 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 appropriate treatment and care according to orders, resident’s preferences and goals.

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

Based on observation, interview, and record review, the facility failed to ensure a that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences for 1 (Resident #1) of 10 residents reviewed for care and treatment. LVN A failed to monitor and assess Resident #1, who had [MEDICAL CONDITION], during and after a breathing treatment and failed to put his oxygen, which he needed at 5 LPM, back on him for approximately three hours. The resident was unattended and experienced respiratory distress, became unresponsive, and subsequently expired in the facility.

On ,[DATE] at 4:48 AM: Resident family and Hospice nurse at bedside. Note was entered by LVN A Telephone interview with LVN A on [DATE] at 11:07 AM revealed that she gave Resident #1 a PRN breathing treatment during the morning of [DATE] (she could not recall exactly what time) and did not remember if she used a mask or mouthpiece. She stated that the resident had both. LVN A stated that Resident #1 requested the breathing treatment. She stated this happened a long time ago and she did not remember everything that happened that day. LVN A stated she assessed the resident before she provided the treatment. She stated she removed Resident #1’s nasal cannula (device used to deliver supplemental oxygen or airflow to a patient or person in need of respiratory help), to administer the breathing treatment. She revealed she stayed in the resident’s room during the nebulizer treatment, but lights in the hall were going off close by and across the hall from the resident’s room so she left to answer them. LVN A stated she could not remember exactly how long she was gone but returned after the treatment was done. She said when she returned to Resident #1’s room, she found him unresponsive. She stated she repositioned him back into bed and placed his oxygen back on him, and no pulse was found. LVN A stated she then left the room to get help with resident. LVN A revealed the aide got the other nurse working in hall that morning. She stated she reassessed the resident when she returned to resident’s room and no pulse was found. LVN A revealed she found Resident #1 with his legs off the bed with the head of bed elevated and his head over towards the side rails. She revealed she then contacted hospice, the doctor and family. She stated she only gave him the one treatment that night. LVN A stated she was aware that resident had an electronic monitoring sign posted outside his room but was not sure it was recording. When revealed to LVN the length of time the video showed she was gone, LVNA stated she did not think she was gone that long.

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.