FORT WORTH, TX- TRAIL LAKE NURSING AND REHABILITATION

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Based on interview and record review, the facility failed to ensure, except when waived, use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 65 days out of 95 days reviewed for weekend RN coverage.

Reasonably accommodate the needs and preferences of each resident.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 5 residents (Residents #3, #6 and #9) reviewed for accommodation of needs.

Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one of six halls (500 Hall) reviewed for environment.
1. The facility failed to properly clean and maintain a sanitary and comfortable environment free of foul odors on hall 500.
2. The facility failed to maintain resident’s wheelchairs in a sanitary and safe operating condition according to 4 residents who attended the confidential group interview.
These failures could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment.

PASARR screening for Mental disorders or Intellectual Disabilities

Based on interview and record review, the facility admitted a resident with a mental disorder before the Stated mental health authority had determined he was appropriately placed for 1 of 7 residents (Resident #37) reviewed for PASARR screening.
The MDS Coordinator failed to complete the PASARR screening process for Resident #37.
This failure could place residents at risk of not receiving specialized services.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Residents #37 and #18) reviewed for comprehensive assessments.
1. The MDS Coordinator failed to ensure Resident #37’s care plan was up to date to include her diagnosis of bipolar disorder.
2. The facility failed to ensure Resident #18’s care plan included her use of Hospice services and correct advanced directive.
These failures could place residents at risk of not receiving all care and services to address diagnoses.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Based on interview and record review, the facility failed to ensure a final summary of the resident’s status at the time of the discharge was available for release to authorized persons and agencies, with consent of the resident or resident’s representative for 1 of 3 residents (Resident #99) reviewed for discharge summary.

The facility failed to complete a discharge summary after Resident #99 left the facility and did not return.

This failure could place residents at risk for a lack of continued care and services.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 5 residents (Residents #19, #37, #9 and #39) reviewed for ADLs.
1. The facility failed to ensure Resident #19 received showers as scheduled for the month of November.
2. The facility failed to ensure Resident #37 received showers as scheduled for the month of November.
3. The facility failed to ensure Resident #9 received showers as scheduled for the month of November.
4. The facility failed to ensure Resident #39 received showers as scheduled for the month of November.

These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Based on observation, interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the resident’s clinical condition demonstrated they were unavoidable for 1 of 3 resident (Resident #15) reviewed for pressure ulcers.

The facility failed to ensure Resident #15’s offloading boot, which was used to prevent skin breakdown, was placed on the resident.

This failure could place residents at risk for the development of pressure injuries.

Provide appropriate foot care.

Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and care to maintain mobility and good foot health for 1 of 7 residents (Resident # 39) reviewed for foot care.

The facility failed to ensure Resident #39 was evaluated and treated by a podiatrist.

This failure could place residents at risk of developing pain or infections.

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Based on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #60) of 3 residents reviewed for enteral feeds.

The facility failed to ensure Resident #60’s enteral feed was properly labeled with the type of formula, date and time it was hung, and the rate of administration.

This failure could place residents at risk of not receiving the proper nutritional requirements prescribed by the physician.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on observation, interview and record review, the facility failed to maintain clinical records in
accordance with accepted professional standards and practices that are complete and accurately
documented for 2 of 5 residents (Residents #15 and #19) reviewed for clinical records.
1. The facility failed to ensure staff accurately documented on Resident #15s MAR.
2. The facility failed to ensure staff accurately documented on Resident #19s MAR.
This failure could affect residents that received medications and place them at risk of inaccurate or
incomplete clinical records.

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident’s attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #18) reviewed for hospice services.
The facility failed to obtain Resident #18’s physician’s order for hospice services.
This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Hire a qualified full-time social worker in a facility with more than 120 beds.

Based on record review and interview, the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis for one of one Social Worker reviewed for qualified social worker, in that: The facility, licensed for 120 beds, had not employed a full-time, qualified social worker since 07/17/23. This deficient practice could result in residents’ social service needs not being met.

Make sure that a working call system is available in each resident’s bathroom and bathing area.

Based on observation and interview, the facility failed to ensure 1 of 7 residents (Resident #39) reviewed for resident call systems had a functioning call light.
The facility failed to ensure Resident #39’s call light was functioning properly.
This failure could place the resident at risk of not receiving care when requested, resulting in a fall.