HARLINGEN, TX- VERANDA REHABILITATION AND HEALTHCARE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 

Based on interview and record review the facility failed to ensure all alleged violations involving neglect, including injuries of unknown source were reported immediately, but not later than 2 hour if the alleged violation resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency for 1 of 4 residents (Resident #22) reviewed for reporting injuries of unknown origin.

The facility did not report within 2 hours when Resident #22 was found on the floor with purple discoloration and a hematoma. Resident #22 was sent to the emergency room , where a CT scan revealed a subarachnoid hemorrhage.

This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being.

The findings include:

Record review of Resident #22’s face sheet, dated 03/03/23, revealed an [AGE] year-old female with an admitted [DATE] with diagnoses which included: Traumatic hemorrhage (bleeding) of right cerebrum (largest part of the brain) without loss of consciousness, subsequent encounter, bacteriuria (presence of bacteria in the urine), dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth or throat), hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of body) following cerebral infarction (type of stroke resulting from blood flow to the brain being disrupted) affecting left non-dominant side and unspecified dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities) , unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety

Record review of Resident #22’s Medicare 5-day MDS dated [DATE] revealed a BIMS score of 05 which indicated Resident #22 had severe cognitive impairment.

Record review of Resident #22’s Medicare 5-day MDS dated [DATE] revealed a Resident #22 required extensive assistance for bed mobility and transfers.

Record review of Resident #22’s fall risk evaluation dated 01/09/23, revealed a score of 11, categorizing Resident #22 as high risk.

Record review of Resident #22’s order summary report retrieved on 03/03/23 revealed physician order for Apixaban Tablet 2.5 MG (used to prevent serious blood clots from forming due to a certain irregular heartbeat (atrial fibrillation) or after hip/knee replacement surgery.) with directions to give 1 tablet by mouth two times a day afib (atrial fibrillation)

Record review of Residents #22’s care plan, with a created date of 10/04/21, revealed Resident #22 was at risk for falls and had a goal of, Will be free of injuries as much as possible related to fall through the review date. Some Interventions included, Anticipate and meet needs, encourage/remind resident to call for assistance, wheelchair dump (wheelchairs the seat angle is usually referred to as the dump and it is measured by how much lower the rear of the seat is than the front of the seat) , continue with roll guards, close supervision while awake, nuero-checks (assessing mental status, carinal nerves, motor and sensory function, pupillary response, reflexes, the cerebellum and vital signs) as ordered, occupational and physical therapy.

Record review of Resident #22’s pain management review dated 01/09/23 at 10:38am revealed

Resident #22 was status post unwitnessed fall and complained of pain to left side.

Record review of Resident #22’s nursing notes documented by LVN C dated 1/09/23 at 15:49 (3:49 PM revealed at 10:38am Resident #22 was found to be on the floor in her room. Resident #22 was found lying in her left side with the left side of her face on the floor and left arm positioned behind her. Resident #22 stated left side and left ankle hurt. Emergency medical services were called, and Resident #22 was taken to emergency room for evaluation and treatment.

Record review of Resident #22’s CT scan impressions from the hospital dated 01/09/23 at 11:59 (11:59AM) revealed there was a subarachnoid hemorrhage identified on imaging.

Record Review of Resident #22’s admission documentation from hospital dated 01/09/23 at 12:45 pm revealed Resident #22 was admitted to the intensive care unit.

Record Review of TULIP (HHSC online incident reporting application) on 03/01/23 at 3:00 p.m., revealed 01/10/23 at 11:27 AM the facility made a self-reported incident involving Resident #22 being found on the floor and sent out to the emergency room . The report was submitted more than 24 hours after Resident #22 was found on the floor and identified by nursing staff to have a hematoma and purple discoloration to face on 01/09/23 at 10:38AM and not within the appropriate 2-hour time frame.

Record review of provider investigation report submitted by the facility dated 01/16/23 revealed LVN D observed Resident #22 with a hematoma and purple to right side of forehead when assisting with Resident #22 on 01/09/23.

During an interview on 03/03/23 at 4:56pm with LVN D she stated the Administrator was the abuse coordination and was responsible for reporting allegations of abuse, neglect, exploitation, and injuries of unknown source to state agencies. LVN D stated she was asked by LVN C to enter Resident #22’s room with her and stated they entered Resident #22’s room at the same time. LVN D stated she was not sure what time or date the incident involving Resident #22 being found on the floor was. LVN D stated Resident #22 was lying flat on the floor and had initial discoloration to the left eye and a raised bump to her head. LVN D stated her and LVN C started to assess Resident #22, checking for deformities, alertness level and took vitals. LVN D stated Resident #22 was cognitively impaired and was not a good historian. LVN D stated Resident #22 was not really able to verbalize what happened. LVN D stated she didn’t think Resident #22’s fall was witnessed and stated she didn’t see anyone else in the room. LVN D stated she was made aware of initial injury to

Resident #22 during her initial assessment when she identified discoloration to left eye and a raised bump to her head. LVN D stated the appropriate time frame to report allegations/incident of abuse, neglect, exploitation or injury of unknown source was immediately. LVN D stated she didn’t report it within the 2-hour time frame to state agencies because she didn’t feel it was neglect.

During an interview on 03/03/23 at 5:19pm with the DON she stated the Administrator was the abuse coordinator. The DON stated both herself and the Administrator were responsible for reporting allegations of abuse, neglect, exploitation, and injuries of unknown source. The DON stated staff were required to complete training over abuse, neglect, exploitation, and reporting annually and several times during the year. The DON stated these trainings were provided by an online program called Relias. The DON stated Resident #22 was cognitively impaired and was not a good historian. The DON was not able to state time or date of incident when Resident #22 was found on the floor. The DON stated she was not there but was notified of incident. The DON stated the Maintenance worker was in the room but did not witness Resident #22 fall. The DON stated staff noticed a bump on her head with discoloration to the face. She stated she was notified by the hospital that she had a bleed. The DON was unable to give exact time and date she was notified by hospital and stated, she reported it to state as soon as she found out from the hospital. The DON stated she was told of hospital findings, the same day the DON was unable to specify what day. The DON stated she did not remember the time she reported to Health and Human Service Commission and stated she didn’t report in time because Resident #22 was in the hospital and I didn’t know anything. When asked why she didn’t report it within a 2-hour time frame, The DON stated as soon as she knows a resident will be sent out it’s kind of like, what triggered that nurse to send them out, there isn’t a definitive. I want to look at it and then determine. The DON stated she monitored incidents and their associated reports were completed and submitted to state agencies in the appropriate time frame by receiving due dates through email after TULIP submissions and stated she kept her files for self-reports separate and dated so she would know the time frame. The DON stated a patient may get injured or abused if she doesn’t report injuries of unknown origin and stated, we would get in a lot of trouble, that’s our part of neglect when asked how not appropriately reporting allegations of ANE or injury of unknown origin that result in serious bodily injury could negatively affect the residents. The DON stated the facility’s policy regarding reporting allegations of abuse, neglect and exploitation or injury of unknown origin which resulted in bodily injury, was to report all cases of abuse and neglect. The DON stated she would have to look at the policy to determine if it was followed.

During an interview on 03/03/23 at 5:30pm the Administrator stated he was the abuse coordinator and responsible for reporting any allegations of abuse, neglect, exploitation, and injuries of unknown origin which resulted in serious bodily injuries. The Administrator stated he received annual training within the company and completed continuing education every year over abuse, neglect, exploitation, injury of unknown origin and reporting. The Administrator stated staff was provided this training via online training system called Relias and though monthly in-services. The Administrator stated the incident involving Resident #22 being found on the floor happened the morning of 01/09/23. The Administrator stated he was notified by the maintenance worker and stated nursing responded by assessing for abnormalities. The Administrator stated Resident #22 was cognitively impaired. The Administrator stated to his knowledge Resident #22 was not able to verbalize what happened. The Administrator stated Resident #22 had initial injuries of discoloration to head and stated she was taking Eliquis. The Administrator stated Resident #22 was taken to the hospital and placed in the intensive care unit. The Administrator stated he was not sure of the findings from the hospital but stated they were available in his provider investigation report. The Administrator stated he knew Resident #22 had a fall and was sent to the hospital and but was unable to give exact time and date he was made aware of injury. The Administrator stated if allegation has seriously bodily injury there is 2-hour time frame to report, when you confirm it.

The Administrator stated he thinks the facility reported it within a 2-hour times frame. The Administrator stated his reasoning for not reporting was due to Resident #22 being on Eliquis and did not know if it was serious or not, stating, a fall could be serious or not serious. The Administrator stated to monitor incidents and their associated reports were completed and submitted to the state agencies within the appropriate time frame the facility followed provider letters and reported according to how we, the best we can interpret it. The Administrator did not specify which provider letter he was referring to. The Administrator stated, it depends on issue when responding to the negative impact not appropriately reporting incidents could have on a resident. The Administrator stated their facility policy on reporting allegations abuse, neglect and exploitation or injury unknown origin resulting in bodily injury followed the guidelines of the provider letter. The Administrator did not specify which provider letter he was referring to. The

Administrator stated he thought their facility policy was followed.

During an interview on 03/03/23 at 6:15pm the Maintenance Director stated he was in Resident #22’s room working on her roommate’s bed, he stated he had previously seen Resident #22 in the hallway maneuvering herself back and forth in her wheelchair. The Maintenance Director stated he did not see Resident #22 enter room. He stated he was on his knees fixing Resident #22’s roommate bed with his back towards Resident #22’s bed when he heard something behind him and turned around to find Resident #22 on the floor. The Maintenance Director stated he alerted 2 nursing staff members. The Maintenance Director stated he did not see or know how Resident #22 fell

During an interview with LVN C on 03/03/23 at 6:23pm she stated she assessed Resident #22 when she was found on the floor on her left side. LVN C stated she identified abnormal findings of swelling, and hematoma to left side of forehead with purple discoloration. LVN C stated she assessed Resident #22, didn’t move her, and called 911. LVN C stated Resident #22 could not verbalize what happened. LVN C also stated she notified all appropriate parties. LVN C stated

Resident #22 was taking Eliquis and stated a head hit can impact her brain with swelling, bleeding and internal bleeding. LVN C stated she didn’t report the incident to any state agencies but did report it to her superiors so they can do what they need to do and make those decisions. LVN C stated she thought the Administrator or DON would report to state agencies

Record review of the facility policy titled Policy/Procedure- Administration with a revision date of 11/28/2017 read a section titled Resident rights and subject of Abuse: Prevention of and Prohibition Against and paragraph titled, H. Reporting/Response read, 2. Allegations of abuse, neglect, misappropriation of resident property or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframe, as per this policy and applicable regulations.