Federal inspectors cited SPJST Rest Home with immediate jeopardy on June 6, finding the facility "failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents."
The violation centered on CNA A, who "attempted to transfer Resident #1 from her bed by pulling her by her arms and hands causing bruising to the resident." The nursing assistant was terminated on June 4, two days before the inspection concluded.
But the termination came only after the facility had already botched its response to confirmed physical abuse.
The Director of Nursing designated an LVN to refer the resident to psychological care on June 4. The facility's psychologist evaluated the resident that same day and reported to the DON that the resident was "doing great." The psychologist planned to continue visits until discharging the resident from psychological services.
On June 4, the DON assessed the resident's hands where injuries occurred during the transfer. The DON determined the resident had no more pain and the injuries were "in the final stages of healing." No follow-up was deemed necessary for the bruises.
The immediate jeopardy citation forced sweeping retraining across the 67-person staff.
The DON and administrator received reeducation on pain and skin assessments from an outside DON on June 5. Starting June 4, the Director of Nursing began retraining all nursing staff on recognizing when residents are in pain and the required response steps.
CNAs received specific training on observing residents grimacing in pain, with instructions to notify the charge nurse immediately. Charge nurses must evaluate residents for pain, take appropriate measures, and document under pain assessment protocols.
If residents have existing pain management orders, charge nurses must follow those orders and check back an hour after treatment to determine effectiveness. When current orders prove ineffective, charge nurses must call the attending physician for additional treatment recommendations. All actions require documentation in progress notes and chart reports.
The Assistant Director of Nursing will monitor all reported pain assessments through 24-hour reports four to five days per week, ensuring nursing staff follow policies appropriately. The ADON reports findings to the DON and administrator weekly, unless noncompliance is discovered, which triggers immediate reporting.
The facility also implemented comprehensive skin assessment protocols. Starting June 4, the DON began in-servicing all nursing staff on when thorough skin assessments are necessary and expected: upon admission, when bruises or skin tears are first noticed, or when residents complain of rough treatment or state they were abused.
Charge nurses became responsible for completing and documenting thorough skin assessments, incident reports, and calling physicians for orders when necessary. Pain assessments must always accompany skin assessments to determine resident pain levels.
When residents are determined to be in pain, charge nurses must follow established pain treatment procedures. The ADON monitors all reported bruises and skin tears to ensure company policies are followed thoroughly, with weekly reporting to the DON and administrator unless policy violations are discovered.
Transfer procedures received intensive focus after the abuse incident. Starting June 4, the DON began in-servicing and retraining staff on transfer policies and procedures. All CNAs and nurses working in patient care areas must perform safe transfers following established procedures.
Education covers stand-by assistance, one-person assists, two-person assists, sliding boards, sit-to-stand lifts, Hoyer lifts, and stand-and-pivot techniques. Trainees must provide return demonstrations to confirm understanding.
The ADON monitors four to five transfers per week for three months to verify company policies and procedures are followed thoroughly. Weekly reporting to the DON and administrator is required unless noncompliance is observed, which triggers immediate reporting.
Abuse and neglect policies underwent complete overhaul. The facility administrator and DON received reeducation from an outside administrator on company abuse policies. The administrator, who serves as the abuse coordinator, in-serviced all facility staff on company abuse and neglect policies and procedures.
Staff received training on reporting requirements: employees witnessing abuse allegations or being told residents were abused or neglected by residents, family members, or visitors must report immediately to the administrator. When the administrator is unavailable, employees report to their immediate supervisor, who then notifies the administrator.
The administrator ensures proper steps are completed and thorough investigations are conducted after reporting allegations to the Texas Health and Human Services Commission. The administrator or designee completes investigations and submits final reports to HHSC according to state regulatory requirements.
Staff unavailable for training sessions by June 7 cannot work on patient care floors until completing appropriate training. This requirement extends to agency staff.
During the June 6 inspection, the DON confirmed her reeducation on pain and skin assessments by DON K from a sister facility. She learned assessments should be completed after incidents, when new skin findings or abnormalities are discovered, when residents have new pain complaints, or after falls.
The DON stated skin and pain assessments should be completed with head-to-toe evaluations for any reports of abuse or neglect. Nurses must evaluate pain by observing non-verbal grimacing and verbal screaming, using a 0-10 scale for verbal residents. Reporting is required for bruises from unexplained injuries within two hours of discovery.
Nurses must document pain medication administration and notify physicians. CNAs must immediately report abuse, neglect, condition changes, or pain to charge nurses.
The DON confirmed learning the facility has five days to complete investigations and submit reports to HHSC. Anyone reporting abuse or neglect to her or the administrator triggers a two-hour reporting requirement to HHSC.
The administrator revealed his reeducation on pain and skin assessments by RN K and Administrator M at a sister facility during his June 6 interview. He learned assessments should be completed whenever anything new is noticed on residents.
CNAs seeing new redness on residents' bodies must report immediately to charge nurses, who then conduct head-to-toe assessments and pain assessments. He confirmed learning that dismissals for abuse or neglect require reporting to licensing authorities within five days.
The administrator stated he will report abuse and neglect to HHSC as soon as possible once his computer is operational.
Record review on June 6 showed 67 staff members were in-serviced on abuse and neglect policy on June 4 by the administrator and DON. Personnel records confirmed CNA A was terminated on June 4.
The immediate jeopardy designation was removed on June 6 at 6:50 PM, but the facility remained cited for potential harm at an isolated scope level. Inspectors determined the facility needs to demonstrate the effectiveness of its corrective systems before full compliance is achieved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spjst Rest Home 1 from 2024-06-06 including all violations, facility responses, and corrective action plans.