PEARLAND, TX – THE COLONNADES AT REFLECTION BAY

Based on observation, interview, and record review, the facility failed to immediately consult with the resident’s physician when there was an accident involving the resident resulting in injury for 1 of 3 residents (Resident #1) reviewed for notification of changes in that: – Resident #1’s physician was not immediately notified when X-ray results identified a possible fracture requiring additional follow up to confirm or exclude the diagnosis. This failure affected one resident and placed her at risk of delayed evaluation and treatment.

During an anonymous interview the person said they felt concerned because the facility delayed the patient receiving care for 22 hours post fall. The person said the patient received X-rays at 11:00 pm and was taken to the hospital the next day.

Observation and interview on 2/15/19 at 5:50 pm revealed Resident #1 was groomed and reclined in her bed. When asked about her fall, she began to cry, and said, They didn’t do what they were supposed to do. I had to beg for an X-ray. They gave me my regular medicine. She said she had complained of pain earlier and knew something was wrong. She said the pain she was having was different from her regular pain. She said, I know in my heart they were wrong.

During an interview on 2/15/19 at 6:39 pm the DON said Resident #1 returned back from the hospital with no records. She said the Nurse Practitioner was called with the X-ray results the night the results were obtained, but, the Nurse Practitioner did not answer and did not call back. She said the Nurse Practitioner came to the facility the next morning around 8:00 am, consulted with the Doctor and Resident #1 was transferred to the hospital. She said looking at the time line, she wished they would have called her (the DON) after not reaching the Nurse Practitioner. She said she would have told them to go ahead and send Resident #1 out and called the NP herself. She said they had no policy and procedure that directly applied to response and delay in sending a resident out.

Record review of a document provided by the DON of the time line of the incident involving Resident #1 revealed the following: 2/11/19 Fall-3:10 pm, 7:45 pm Resident #1 complains of pain to left hip and X-rays were ordered. 2/12/19: 12:28 am-X-ray received to facility, X-ray result was inconclusive when reviewed by the NP (Nurse Practitioner) 9:00 am -NP reviewed X-ray again with the MD, 11:00 am -new order to transfer Resident #1 to local hospital for more in depth X-ray to confirm fracture.

During an interview on 2/15/19 at 6:45 pm the Administrator said he would have gone ahead and sent Resident #1 to the hospital, it was pain.