Estates Healthcare And Rehabilitation Center

The facility failed to provide adequate supervision to prevent Resident #99, who had cognitive impairment and resided on the secure unit, from eloping from the facility on 02/03/25 when the resident pried open the window in his room and made it 0.9 miles away from the facility.

An Immediate Jeopardy was identified on 02/12/25 at 3:50 PM.

While the Immediate Jeopardy was removed on 02/14/25, the facility remained out of compliance at the severity level of Potential for more than minimal harm that was not immediate jeopardy and a scope of Isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

2.

The facility failed to provide adequate supervision and assistive devices to Resident #67 on 02/06/25 when he was not properly secured on the facility's van, which resulted in the resident falling backwards in his wheelchair and hitting his head on the floor of the van during takeoff in the facility's parking lot. Resident #67 was sent to hospital resulting where he was evaluated and treated for head injury and a contusion of the right hand .

An IJ was identified on 02/13/25.

The IJ template was provided to the facility on [DATE] at 5:20 PM.

While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that was not Immediate Jeopardy, due to the facility's need to implement corrective systems.

This failure could place residents at risk for severe injury or harm, decline in health, and decreased quality of life and death.

Findings included:

1.

Record review of Resident #99's Admission Record dated, 02/12/25, reflected the resident was a [AGE] year old male with an initial admitted [DATE] and readmitted [DATE]. Resident #99's diagnoses included: unspecified dementia, muscle wasting and atrophy, depression, and chronic kidney disease.

Record review of Resident #99's Optional State Assessment MDS dated , 01/18/25, reflected the resident's original admitted [DATE] and readmitted [DATE]. Resident #99's MDS also reflected the resident was mildly impaired with a BIMS of 8.

The MDS also reflected in Section E900 Wandering Frequency occurred 1 to 3 days per week.

675028

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 675028 B.

Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134

According to Resident #67 he had a headache and pain in his right hand from the fall. Resident #67 stated it was not the facility van driver, but an outside provider that was taking him to his appointment. Resident #67 stated he took off like a race car driver in the parking lot and I fell backwards, hitting my head on the floor, and blacked out. Resident #67 stated the van driver did not strap me down correctly, so when he took off, I fell backwards and hit my head, and was sent to the hospital.

Interview on 02/13/25 at 12:28 PM the DON revealed she knew Resident #67 was scheduled for urology appointment on 02/06/25, she stated the facility van had other appointments, so he was to be transported by an outside transport provider.

The Social Worker stated she did not see Resident #67 exit the building for his appointment.

The DON stated she was alerted to come outside.

When she got outside, she saw Resident #67 still in his wheelchair; straps were still attached.

According to the DON she jumped in the van and removed 2 straps, she stated Resident #67 had to be removed from the chair so they could get the wheelchair out the van.

Once the wheelchair was removed from the van, Resident #67 was placed back in the wheelchair, assessed and was one on one with nurse until the emergency medical services arrived to take him to the hospital.

The DON stated Resident #67 was delirious and was not able to support his body while sitting in the wheelchair, he was not at his baseline , he complained of head pain and stated that he lost consciousness.

The DON stated she did not speak to the Van Driver; she did not recall if an incident report was completed.

According to the DON drivers were responsible for entering the facility to transport residents out and back inside upon returning to the facility.

Interview on 02/13/25 at 2:47 PM with Social Worker revealed when residents require an outside appointment, they will leave notification for the Facility Transportation Driver to schedule the appointment with the provider and arrange transportation.

According to the Social Worker, she was alerted by the Van Driver coming to the door saying, your patient has flipped out here in the van, the Social Worker stated at that point she alerted either the Administrator or the DON.

The Social Worker stated when she got outside, she saw Resident #67 laying on his back yelling at the Van Driver you fucking dropped me, there was no way I was strapped in.

According to the Social Worker Resident #67 and the Van Driver was going back and forth indicating Resident #67 was upset.

The Social Worker stated she saw he was strapped in however could not tell if it was done correctly.

She stated there was one strap on each front wheel but did not recall if the back wheels had any straps, she further stated there were straps caught in the wheels and it was a lot of trouble getting the straps out the wheelbase.

675028

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 675028 B.

Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Estates Healthcare and Rehabilitation Center 201 Sycamore School Rd Fort Worth, TX 76134