Azle Manor Health Care And Rehabilitation
Azle Manor Health Care and Rehabilitation in Azle, TX — inspection on June 6, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to ensure Resident #1 was properly assessed, monitored, and received effective pain management after Resident #1 fell on [DATE] at approximately 4:30 PM and sustained a comminuted fracture of the left distal femur just above the femoral condyles and was not sent to the hospital for treatment for 6.5 hours at approximately 11:00 PM.
The nurse was not notified for 1 to 1.5 hours of the fall until Resident #1's family member intervened and notified the nurses of Resident #1's pain.
An immediate Jeopardy (IJ) situation was identified on 6-5-2024 at 5:41 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of its corrective systems.
These failures placed residents at risk of experiencing significant pain and discomfort.
Findings Included:
Record review of Resident #1's Face Sheet dated 6-4-2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Alzheimer's Disease with late onset, and secondary diagnosis of Dementia, Cerebral Infarction (Stroke), and Need for Assistance with Personal Care.
Record review of Resident #1's Comprehensive MDS Assessment, dated 3-25-2024, revealed Resident #1 had a BIMS Score of 11 indicating moderate cognitive impairment.
The Functional abilities and goals section revealed Resident #1 was Dependent (Helper does all of the effort.
Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers were required for the resident to complete the activity) for upper body/lower body dressing, bathing, and Chair-to-bed transfers.
Because of Resident #1's medical conditions or safety concerns, Resident #1 was coded for there to be no attempt made by staff to move Resident #1 from Lying to sitting on side of bed. Resident #1 had a diagnosis of stroke, brain and spinal cord dysfunction, amputation, hip and knee replacement, fractures, and other multiple traumas.
Record review of Resident #1's doctor orders revealed an order for Norco Oral Tablet 325 MG to being on 5-28-2024 to be given for pain every 6 hours as needed for pain.
676003
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676003 B.
Wing 06/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Azle Manor Health Care and Rehabilitation 721 Dunaway LN Azle, TX 76020
F-F697 related to the alleged action of pain by not providing pain medication. By submitting this plan of removal Azle Manor does not admit to the accuracy of the alleged deficient practice.
What corrective actions have been implemented for the identified residents?
o Residents residing in the facility are assessed for pain every shift and after incidents/accidents.
On 6/5/24 the DON/designee completed audits on residents receiving routine and PRN pain medications to determine appropriate timing and resident response to effectiveness of treatment modalities; and
On 6/5/24 the DON/designee completed audits on residents with active pain assessments to determine accuracy in level of pain and update the treatment plan
How were other residents at risk to be affected by this deficient practice identified?
All residents residing in the facility are at risk for pain.
Pain assessments are completed every shift, as needed, and following incidents/accidents.
What does the facility need to change immediately to keep residents safe and ensure it does not happen again?
The DON/designee initiated immediate training on 6/5/24 and completed training on 6/6/24 with CNA Student(s), CNA(s), Medication Aides, and Licensed Nurses to include areas of:
o Assessing pain/pain complaints.
o Modalities of assessment to include those with communication difficulties and/or cognitive issues.
How will the system be monitored to ensure compliance?
676003
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676003 B.
Wing 06/06/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Azle Manor Health Care and Rehabilitation 721 Dunaway LN Azle, TX 76020