LEAGUE CITY, TX - The Heights of League City nursing facility received immediate jeopardy citations from federal inspectors following a resident's death linked to critical failures in oxygen therapy management and medication order entry.
Fatal Breakdown in Admission Process
Federal inspectors determined that a newly admitted resident requiring continuous oxygen therapy died after nursing staff failed to properly enter physician orders into the facility's electronic health record system. The resident, identified as CR #1, was admitted with multiple serious conditions including heart failure, diabetes, morbid obesity, and atrial fibrillation.
According to inspection documents, the resident was prescribed continuous oxygen therapy by hospital physicians upon discharge, but the admitting nurse failed to enter this critical order into the facility's computer system. This breakdown occurred despite the resident's documented need for respiratory support due to acute on chronic heart failure.
The facility's Director of Nursing acknowledged that "LVN H missed entering the oxygen order in the computer, and ADON J, who did the chart check, did not realize LVN H did not enter the oxygen order in the computer."
Oxygen Therapy Management Failures
Critical oxygen requirements were not met due to systematic failures in the admission process. Federal regulations require nursing facilities to ensure residents receive prescribed respiratory care, including proper oxygen therapy management.
Oxygen therapy is essential for residents with heart failure because the condition reduces the heart's ability to pump blood effectively throughout the body. When residents don't receive prescribed oxygen therapy, they face increased risks of respiratory distress, organ dysfunction, and potentially fatal complications.
The inspection revealed that 12 residents in the facility required continuous oxygen therapy, with an additional 7 residents needing supplemental oxygen. Following the incident, facility leadership conducted a comprehensive review of all residents requiring oxygen therapy to verify proper physician orders were documented.
Therapeutic Diet Order Discrepancies
In addition to oxygen therapy failures, inspectors documented that the same resident received incorrect dietary treatment throughout their stay. Hospital discharge orders specified a cardiac diet with 2-gram sodium restriction, low fat, and low cholesterol requirements - critical for managing heart failure and preventing fluid retention.
However, nursing staff entered a regular diet order into the computer system instead of the prescribed cardiac restrictions. The facility's dietary manager confirmed she provided regular meals based on the incorrect computer order, rather than the therapeutic diet specified in hospital discharge instructions.
Cardiac diets are medically necessary for residents with heart failure because excess sodium can worsen fluid retention, increase blood pressure, and strain the cardiovascular system. Regular diets typically contain significantly more sodium than the 2-gram daily limit prescribed for cardiac patients.
Systemic Communication Breakdowns
The violations revealed broader communication failures between nursing staff, therapy teams, and dietary services. Inspection findings showed that therapy staff were not consistently notified when residents experienced changes in condition, and the facility lacked proper procedures for coordinating care between departments.
Federal inspectors noted that physical therapy and occupational therapy staff had not received adequate training on reporting procedures when residents on oxygen therapy experienced respiratory changes during treatment sessions.
The facility's rehabilitation director was subsequently required to attend daily morning meetings where residents requiring oxygen therapy are reviewed, ensuring better coordination between nursing and therapy services.
Immediate Response and Corrective Actions
Following identification of the immediate jeopardy situation, facility leadership implemented extensive corrective measures. All licensed nurses received emergency training on medication reconciliation procedures for newly admitted residents, with specific emphasis on accurately transcribing hospital discharge orders.
The facility established new protocols requiring charge nurses to notify physicians immediately upon admission and review all hospital discharge orders before entering treatments into the electronic health record. Nursing supervisors now conduct daily chart audits to verify accurate order entry for all new admissions and readmissions.
Staff competency validations were implemented for all licensed nurses to ensure proper understanding of physician order entry procedures. The facility also instituted mandatory skills check-offs for staff regarding resident care plan access and change-of-condition reporting protocols.
Enhanced Monitoring Systems
New monitoring procedures require daily review of all residents receiving oxygen therapy during morning meetings, with therapy staff receiving copies of oxygen monitoring reports. The facility implemented a comprehensive tracking system to ensure residents requiring portable oxygen receive proper equipment during transfers and therapy sessions.
Direct care staff received additional training on using the facility's Kardex system to access resident care information and understand equipment needs before providing care. This training addresses the critical need for staff to understand each resident's specific medical requirements and equipment dependencies.
Industry Standards and Best Practices
Federal nursing home regulations require facilities to ensure residents receive treatment and care according to physician orders and professional standards of practice. Proper medication reconciliation during admission is a fundamental safety requirement that prevents treatment gaps and medical errors.
Oxygen therapy management requires trained nursing staff who understand proper equipment operation, monitoring requirements, and emergency procedures. Residents requiring continuous oxygen therapy need regular monitoring of oxygen saturation levels and immediate response to respiratory changes.
Therapeutic diet management involves coordination between nursing staff, dietary services, and physicians to ensure residents receive nutritionally appropriate meals that support their medical treatment plans. Cardiac diets specifically help manage fluid balance and cardiovascular stress in residents with heart conditions.
Ongoing Compliance Monitoring
The facility remains under enhanced federal oversight with requirements for intensive monitoring over a two-month period. Nursing leadership must conduct weekly skills validations and daily admission order reviews to demonstrate sustained compliance with medication reconciliation procedures.
All therapy staff received training on change-of-condition reporting requirements, with random competency checks scheduled throughout the monitoring period. The facility's Quality Assurance and Performance Improvement committee will review monitoring findings during monthly meetings to identify any additional training needs.
Federal inspectors confirmed the immediate jeopardy was removed following implementation of corrective measures, but the facility remains cited for violations related to incomplete staff training on admission procedures and care coordination protocols.
The Heights of League City incident highlights the critical importance of accurate order transcription and interdisciplinary communication in nursing home care, particularly for residents with complex medical conditions requiring specialized treatments and dietary management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regent Care Center of League City from 2025-01-13 including all violations, facility responses, and corrective action plans.
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