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F0561
D

Failure to Honor Resident's Request for Hospital Evaluation

San Angelo, Texas Survey Completed on 05-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to honor a resident's request to be sent to the hospital for evaluation. The resident, who had diagnoses including acute recurrent sinusitis, shortness of breath, hemiplegia, and hemiparesis, and was assessed as having intact cognition, reported feeling unwell and requested to go to the hospital. The resident used her call light multiple times to communicate her request to CNA A, who relayed the information to LVN B. Despite these repeated requests, there was no documented assessment, vital signs, or progress notes regarding the resident's condition or her request to be sent to the hospital on the date in question. The resident ultimately contacted her significant other to take her to the hospital after several hours without nursing intervention. Interviews revealed that the DON was unaware of the resident's initial request and believed that staff should have evaluated the resident, obtained vital signs, and contacted the physician. LVN B did not recall being informed of the resident's request and stated she would typically assess and obtain vital signs if a resident was unwell. The facility's policy affirms the resident's right to request treatment or care. The lack of timely nursing assessment and response to the resident's repeated requests resulted in the resident leaving the facility to seek care independently, where she was diagnosed and treated for a urinary tract infection and acute airway inflammation.

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