Failure to Provide IV Antibiotic Therapy Due to Lack of RN
Summary
The facility failed to implement its admissions policy and procedure when it admitted a resident from a general acute care hospital for intravenous (IV) antibiotic therapy without having a registered nurse (RN) on duty to administer the medication. This resulted in the resident not receiving the prescribed IV antibiotic medication and necessitated the resident's return to the hospital just three hours after admission. The resident was admitted with diagnoses including bacteremia, dementia, major depressive disorder, and anxiety, and required IV vancomycin every 12 hours for MRSA bacteremia. Interviews and record reviews revealed that the facility's staff, including the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), were aware of the resident's need for IV antibiotics but were unable to provide the necessary care due to the absence of an RN. The LVN, who was the charge nurse at the time, informed the DON and the resident's responsible party about the situation, leading to the decision to send the resident back to the hospital. The facility's Marketing Director/Admissions also acknowledged that the resident should not have been transferred to the facility without the availability of an RN to administer the medication. The facility's policy and procedure for admissions, which aims to ensure that residents who can be adequately cared for are admitted, was not followed in this instance. The failure to coordinate and ensure the availability of appropriate nursing staff to administer the required IV medication directly led to the deficiency. The facility's job description for the Admissions Director emphasizes the need to coordinate with the Director of Nursing to assure the appropriateness of facility admissions, which was not effectively executed in this case.
Penalty
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Incomplete admission packets and resident rights notices: The facility failed to complete admission agreements and orientation packets for three residents. One resident had severely impaired cognition and required extensive assistance, while two others had moderate cognitive impairment and needed varying levels of ADL support. The Admissions Assistant reported delayed or unsuccessful attempts to obtain signatures, and some packets were later marked refused without documented evidence of timely completion attempts or full provision of the required admission materials, including Medicaid rights information.
Failure to prepare for a scheduled admission led to a resident being sent back to the hospital. The resident had been approved for SNF/SAR placement after hospitalization for SOB and leg swelling, and management emails announced the admission, but the admitting nurse said she had no notice, no hospital report, and found the room not ready. The LPN told the resident's son and ambulance staff she could not accept the resident, and the resident was returned to the hospital.
Admission Agreement Included Improper Waiver of Liability for Resident Property: The facility’s admission agreement stated that the facility was not responsible for any resident property that was lost, damaged, or stolen, and it was used for two residents with intact cognition. One resident’s wallet money was reported missing, and another resident reported missing cash after discharge; both incidents were investigated and reported to HHSC, but the agreement still contained language requiring residents to waive potential facility liability for lost personal property.
The facility failed to protect residents’ rights to Medicare benefits by changing several residents from Medicare managed plans to Traditional Medicare without clear request, consent, or understanding. Staff did not have a written policy for assisting with coverage changes, and records lacked required consent, NOMNC, or supporting documentation for the plan changes. Interviews showed some residents and representatives were unaware of the changes, while staff described discussing plan changes with residents after NOMNCs and training others to do the same.
A resident with DM, diabetic CKD, and HD dependence was assigned a bed and report was taken, but when the resident arrived, the facility sent the resident back to the GACH ER because HD transportation had not been authorized. The RN stated the admission policy was not followed, and the SSD said the resident could have been admitted while transportation benefits or out-of-pocket payment were arranged.
Failure to complete admission paperwork for a resident admitted for rehab after a stroke. The resident had intracerebral hemorrhage, disorientation, atrial fibrillation, and severe cognitive impairment (BIMS 4/15). Family said only consent to treat and code status forms were signed at admission, while the rest of the packet was delayed, then later emailed for signature. Staff later told the family the resident’s insurance was not covered and there was a $6,000 balance, and the ED said the facility would absorb the cost.
Incomplete admission packets and resident rights notices
Penalty
Summary
The facility failed to complete admission packets, including admission agreements and orientation packets, for three sampled residents upon admission as required by its policy. The report states that the facility’s policy required admission agreements and legal papers to be completed at the time of admission, and that residents were to be informed orally and in writing of their rights, rules, and Medicaid rights and obligations. The deficiency involved Resident 1, Resident 3, and Resident 4, whose packets were not completed within the expected timeframe and were later marked as refused or left incomplete. Resident 1 was originally admitted with diagnoses including encephalopathy, acute respiratory failure with hypoxia, end stage renal disease, and dependence on renal dialysis. The MDS showed severely impaired cognition and dependence on staff for transfers, toileting/personal hygiene, showering, lower body dressing, and bed mobility. The admission packet showed that the RP refused to sign the acknowledgment portion, and the Admissions Assistant stated the first contact to complete the packet occurred after the resident’s readmission, with the response from the RP not received until later, at which point the packet was documented as refused. Resident 3 was admitted with acute respiratory failure with hypoxia and acute pulmonary edema, and the MDS showed moderately impaired cognition with assistance needed for toileting hygiene, showering, dressing, transferring, oral/personal hygiene, and bed mobility. The Admissions Assistant stated a message was left for the RP to complete the packet, but there was no response and no documented evidence of attempts to contact either the RP or the resident. Resident 4 was admitted with right hip fracture, history of fall, and bilateral primary osteoarthritis of the knee, and the MDS showed moderately impaired cognition with assistance needed for shower transfers, toileting/personal hygiene, showers, dressing, and bed mobility. The Admissions Assistant stated the resident said the packet would be signed later because it was too long, but the packet was later marked refused and the assistant could not provide documented evidence of attempts to complete it.
Failure to Prepare for Scheduled Admission
Penalty
Summary
The facility failed to properly prepare for the arrival of a resident who had already been pre-screened and approved for placement, resulting in the resident being returned to the hospital. The resident was expected for admission to the facility for short-term rehabilitation after hospitalization for shortness of breath and leg swelling, and the hospital referral indicated the resident would benefit from skilled therapy and was recommended for SNF/SAR placement. Facility email threads showed the admission was announced to management, including that the resident was coming to the facility on a Sunday at 2:00 PM. During interviews, the Facility Liaison stated the resident was not admitted because the nurse did not know the resident was coming. The RDO stated the facility knew the resident was supposed to be admitted, but the admitting nurse did not receive the information directly and believed weekend admissions were not being taken. LPN10 stated she saw the ambulance arrive but had no idea there was an admission, had no hospital report, found the room not ready and the bed not made, and told the resident's son and ambulance personnel that she could not accept the resident. The resident remained on the stretcher and was returned to the hospital.
Admission Agreement Included Improper Waiver of Liability for Resident Property
Penalty
Summary
The facility failed to implement an admissions policy that did not request or require residents to waive potential facility liability for loss of personal property. The deficiency involved 2 of 2 residents reviewed for loss of personal property. Resident #1 was a female with diagnoses including heart failure, hypertension, and respiratory failure, and her BIMS score was 14, indicating intact cognition. Her record reflected that she was admitted to the facility and later discharged, and a grievance completed by the Administrator documented that her son reported money missing from her wallet between Friday evening and Sunday morning, with the amount estimated between $140 and $200. The item was not located, no one confessed to taking it, and the incident was reported to HHSC. Resident #2 was a female with diagnoses including hypertension, aftercare following joint replacement surgery, and presence of a left artificial knee joint. Her BIMS score was 15, indicating intact cognition. Her grievance, also completed by the Administrator, documented that after discharge home she believed she was missing $100 cash. The item was not located, staff interviewed did not see a purse or wallet, and the incident was reported to HHSC. Interview with the Administrator confirmed the incidents were investigated and inconclusive, and he stated the facility’s admission agreement was from the previous company and still included language stating the facility was not responsible for any resident property that was lost, damaged, or stolen.
Unauthorized Medicare Plan Changes
Penalty
Summary
The facility failed to protect residents’ rights to Medicare benefits by disenrolling five residents from Medicare Managed Health Plans without their request, consent, knowledge, or complete understanding. Surveyors found that the facility did not have written policies and procedures for assisting beneficiaries with changes to health care coverage, including when staff could assist with a plan change and the requirement for an attestation signed by the staff member who assisted with the enrollment change. The facility also did not provide the requested policy when surveyors asked for it, and a nurse consultant stated the facility did not have such a policy. For one resident, records showed admission on Managed Medicare and transition to Traditional Medicare, with facility attestations completed by social services staff stating the resident’s spouse or the resident requested the change; however, the forms did not contain the required acknowledgement signature from the resident or representative. The resident was not aware of any insurance change, and the representative stated they were not aware of or did not remember any discussion about changing the insurance. For another resident, the resident stated a staff member talked to them about changing insurance and said it would be better, while the resident also said they could not afford it and later received mail showing the insurance had been dropped. For two additional residents, records showed a transition from Managed Medicare to Traditional Medicare effective the same date, but there were no NOMNCs, progress notes, or consent forms supporting that the residents or representatives requested the changes. One resident stated the facility changed the insurance so they could stay in the facility longer and that staff initiated the conversation. Another resident denied requesting the change and denied signing any documents. For a fifth resident, the representative stated they had no idea how the change happened and had already changed it back, while staff interviews showed staff had been trained to tell residents that if they received a NOMNC and were concerned about going home, they could appeal, apply for Medicaid, or switch to Traditional Medicare to receive therapy longer.
Failure to Evaluate Admission Needs Before Sending Resident Back to Hospital
Penalty
Summary
The facility failed to evaluate and determine the level of care needed for one resident before admission, as required by its Transfer and Discharge policy. The resident was admitted with diagnoses including type 2 diabetes with diabetic chronic kidney disease and dependence on renal dialysis, and the History and Physical dated 7/14/2026 indicated the resident had the capacity to understand and make decisions. During interview, the admission coordinator/marketer/LVN stated a bed had been assigned and report was taken by the facility RN, but when the resident arrived, the resident was sent back to the GACH ER because the facility did not have authorization for hemodialysis transportation scheduled for Tuesday, Thursday, and Saturday. The RN stated the facility’s policy for newly admitted residents was to call the admitting doctor and receive orders for what the facility should do, but that this was not followed in this case. The RN also stated the resident was sent back to GACH, which placed the resident in danger of a health decline during transportation. The Social Service Director stated the resident could have been admitted and transportation benefits could have been obtained in the morning, or the administrator could have authorized payment out of pocket since the resident had already been admitted. The facility’s policies stated residents are admitted under orders of the attending physician, the facility will evaluate and determine the level of care needed prior to admission, and social services will help arrange transportation when insurance does not cover the cost.
Failure to Complete Admission Paperwork
Penalty
Summary
The facility failed to implement its admissions policy for one resident, who was admitted for rehab after a stroke and had diagnoses including intracerebral hemorrhage, disorientation, and atrial fibrillation. The resident’s admission MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. Review of the resident’s EHR showed admission on 05/21/2026 and discharge on 05/27/2026, but there was no evidence of signed admission paperwork anywhere in the chart. The facility’s admission policy stated it would maintain an admissions policy to ensure fair and impartial admission practices. The resident’s family member stated she was present at admission and signed only a consent to treat form and a code status form, and that she repeatedly asked about the remaining admission paperwork but was told it would be completed later. She stated the paperwork was eventually emailed to her and she was asked to sign and return it, but she wanted time to review it first. At the resident’s first meeting, staff told the family there was a problem with the resident’s insurance and that the stay was not covered, with a balance of $6,000 owed; the Executive Director later stated the facility would cover the cost and the resident was not responsible. Facility staff stated the expectation was that all admission paperwork would be completed and signed within 48 hours of admission, but the Admissions Director said the insurance verification team made a mistake and she was not sure why the paperwork was not presented for signature before discharge.
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