Vidor Health & Rehabilitation Center

Review of the

jeopardy to resident health or - Quality of Care

The facility failed to follow up after notifying the NP twice regarding Resident #1's safety phenytoin lab value of 5.6 on [DATE] and no intervention or assessments were put in place.Interventions:Resident #1 was transferred to the hospital on [DATE] for treatment of status

2.26.26 DON, ADON, or Designee completed a 100% audit of: anticonvulsant to ensure therapeutic lab values.

Any abnormal findings will be communicated to the Attending Physician.

Completed 2.26.26.

One abnormal lab on resident, provider notified, awaiting for any new orders.

Resident has no s/s of symptoms of seizures.

The DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services.

Completed 2.26.26.Provider notification of abnormal labs values to include the NP, MD, and Medical Director.

The charge nurse will notify the provider and document communication and orders.Documentation of provider notification for changes of condition including changes in condition as a result of abnormal lab values.Escalation: when the charge nurse notices that the NP doesn't address non-therapeutic labs values, then the nurse will call the attending physician. if the attending physician doesn't address non-therapeutic labs values, then the charge nurse will call the medical director.Abuse and neglect- Failure to intervene on abnormal lab values could be considered neglect.

The Medical Director was notified of the Immediate Jeopardy on 2.26.26 by the DON. An ADHOC QAPI meeting was completed by the interdisciplinary team to include the Medical Director on 2.26.26 In-services:The following in-services were initiated on [DATE] for all charge nurses by the DON, ADON, and/or Regional Compliance Nurse in person and/or via phone.

All staff not present for in-servicing will not be permitted to work their assignment until in-serviced.

All new hires will be in-serviced during facility orientation.

All agency staff will be in-serviced prior to working their floor assignment.

Completed [DATE].Provider notification of abnormal labs values to include the NP, MD, and Medical Director.

The charge nurse will notify the provider and document communication and orders.Documentation of provider notification for changes of condition including changes in condition as a result of abnormal lab values.Escalation: when the charge nurse notices that the NP doesn't address non-therapeutic labs values, then the nurse will call the attending physician. if the attending physician doesn't address non-therapeutic labs values, then the charge nurse will call the medical director.Abuse and neglect- Failure to intervene on abnormal lab values could be considered neglect. On [DATE] the facility wide anti-convulsant audit was reviewed, the documentation of Resident #2's follow up to their abnormal lab was reviewed, and the in-service documentation for the ADON, DON, and all staff were reviewed.

Any in-services that have not bee completed, will be done before their next shift. On [DATE] individual staff interviews were conducted with LVN A, ADON C, RN G, LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, and LVN N from 9:15 a.m. to 12:00 p.m.

Staff represented all three shifts including weekends and PRN staff.

Staff were asked to describe the training they had received.

All employees interviewed were able to correctly answer questions and described all types of lab results that would be reported to the DON, MD, and family. On [DATE] at 12:00 p.m. the Administrator was informed the IJ was removed.

While the IJ was removed the facility remained out of compliance at a severity level of no actual harm that was not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor to ensure the implementation and effectiveness of their plan of removal.