Mcallen Nursing Center
MCALLEN NURSING CENTER in MCALLEN, TX — inspection on August 17, 2025.
Found 1 citation. 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
During an interview on 08/17/2025 at 04:50 pm, The SW stated when she was notified of a resident-to-resident altercation, she would notify the administrator, would interview the residents involved once a day for 72 hours, and document the altercation and the interviews in PCC (electronic health record).
The SW stated the administrator notified her of the altercation between Resident #1 and Resident #2.
She said she followed protocol.
During an interview on 08/17/2025 at 05:13 pm, the DON stated LVN B no longer worked at the facility. LVN B was one of the nurses working when the resident-to-resident occurred. In an attempted interview on 08/17/2025 at 05:15 pm, LVN C was not reachable.
Her voice mailbox was full. No voicemail left. LVN C was the nurse who was involved with the resident-to-resident altercation. In an attempted interview on 08/17/2025 at 05:21 pm, LVN D was not reachable. A voicemail was left.
There was no return call. In an attempted interview on 08/17/2025 at 05:22 pm, LVN E was not reachable. A voicemail was left.
There was no return call.
During an interview on 08/17/2025 at 05:30 pm, the DON stated for a resident-to-resident altercation, skin, vital signs, what the nurse did, how it happened, residents involved, that the residents were separated, etc., were to be documented on.
The DON stated she could guess what happened and why there were no notes in Progress Notes about the resident-to-resident altercation between Resident #1 and Resident #2.
She said the nurse's notes had not transferred over from the Incident Report the nurse completed for the resident-to resident altercation.
The DON could not produce the incident report written by LVN C.
Record review of facility's policy Clinical Document Guideline dated original date 03/14/2022, revised dated 03/25/2014, and reviewed date of 02/14/2020 revealed: PolicyThe patient's clinical record provides a record of the health status, including observations, measurements, history, and prognosis which serves as the primary document describing healthcare services provided to the patient.Fundamental InformationThe clinical record is used by the healthcare team to record, preserve, and to communicate the patient's progress and current treatment.DocumentationClinical record progress notes, physician orders, flow records.
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