Citations in Texas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Texas.
Statistics for Texas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Texas
A resident with multiple diagnoses, including Alzheimer's and Parkinson's disease, experienced an unwitnessed fall in her room resulting in a subdural hematoma and subarachnoid hemorrhage. Despite the serious injury and regulatory requirements, the facility did not report the incident to the State Survey Agency within the mandated two-hour timeframe, as staff believed the circumstances of the fall were known. Facility policy requiring such reporting was not followed.
A resident with multiple diagnoses suffered an unwitnessed fall resulting in serious head injuries, but the facility did not conduct or document a thorough investigation or report the incident to the state health authority, as required by policy. Interviews with the DON and Administrator confirmed that no self-report or in-service training was completed following the event.
A medication cart was left unlocked and unattended by an LVN during a medication pass while she checked on a resident, contrary to facility policy requiring carts to be secured at all times. The DON confirmed the LVN was new and reiterated the importance of locking medication carts, as outlined in facility procedures.
Surveyors found that the facility did not have an infection prevention and control program in place, as required. This deficiency was identified through direct observation and review of facility records.
The facility failed to ensure the kitchen dishwasher consistently reached the manufacturer's recommended wash and sanitize temperatures, with multiple recorded instances of substandard temperatures and a lack of reporting by dietary staff. The issue persisted despite posted instructions and recent equipment replacement, and no dish sanitization policy was provided when requested.
Two residents with COPD who were receiving oxygen therapy did not have required oxygen in use signage posted on their doorways, despite facility policy and staff expectations. Observations and staff interviews confirmed the absence of signage while the residents were using oxygen, and administrative staff acknowledged the deficiency.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
Surveyors found that medication and treatment carts containing drugs and biologicals were left unlocked and unattended by nursing staff, contrary to facility policy and professional standards. Interviews with LVNs and the DON confirmed that carts should have been locked when not in use, but this protocol was not followed, resulting in unsecured access to medications.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A nurse failed to disinfect a glucometer between uses on two residents, both with diabetes and sepsis, despite facility policy requiring disinfection after each use. The nurse performed hand hygiene but did not clean the device before attempting to use it on a second resident, and the DON confirmed that staff are expected to use approved chemical wipes for bloodborne pathogens between each use.
Failure to Timely Report Serious Injury of Unknown Origin
Penalty
Summary
The facility failed to report an incident of an unwitnessed fall resulting in serious injury for one resident within the required two-hour timeframe to the State Survey Agency, as mandated by regulation and facility policy. The resident, an elderly female with Alzheimer's disease, anxiety disorder, and Parkinson's disease, was identified as being at risk for falls and was ambulatory with a walker. On the date of the incident, she was found on her bedroom floor with blood on the back of her head and complaints of neck and back pain, less than 30 minutes after last being seen in bed by staff. She was subsequently transported to the hospital, where she was diagnosed with a subdural hematoma and subarachnoid hemorrhage related to the unwitnessed fall. Despite the serious nature of the injury and the requirement to report such incidents of unknown origin within two hours, the facility did not notify the State Survey Agency. Interviews with the DON, Administrator, LVN, and CNA confirmed that the event was not reported because staff believed the circumstances of the fall were known, as it occurred in the resident's room. The facility also did not provide in-service training to nursing staff related to this incident, as it was not self-reported to the authorities. The facility's own policy required reporting injuries of unknown origin with serious bodily injury, but this was not followed in this case.
Failure to Investigate and Report Injury of Unknown Origin with Serious Bodily Injury
Penalty
Summary
The facility failed to provide evidence that all allegations of injuries of unknown origin involving serious bodily injury were thoroughly investigated and documented for one resident. Specifically, a female resident with Alzheimer's disease, anxiety disorder, and Parkinson's disease experienced an unwitnessed fall in her room, resulting in blood on the back of her head, complaints of neck and back pain, and subsequent hospital admission where she was diagnosed with a subdural hematoma and subarachnoid hemorrhage. Despite the serious nature of the injury, there was no facility self-report investigation or documentation of a thorough investigation related to the incident. Interviews with the DON and Administrator confirmed that the event was not reported to the state health authority, and no in-service training or internal investigation was completed, as the facility believed the circumstances of the fall did not require reporting. Review of facility policy indicated that such incidents should be reported and investigated, but this was not followed in this case.
Medication Cart Left Unlocked and Unattended by LVN
Penalty
Summary
A medication cart on the second hallway was observed left unattended and unlocked by an LVN during a medication pass. The LVN stated in an interview that she had left the cart unsecured while checking on a resident, which she claimed was not her usual practice. She acknowledged that leaving the cart unlocked could allow unauthorized access to medications, potentially leading to misappropriation or misuse. The Director of Nursing (DON) confirmed that the LVN was a relatively new staff member and emphasized the importance of securing medication carts at all times. The facility's policy requires that medication carts be locked if left unattended, even in emergencies. The DON also described oversight measures in place, including random checks and daily monitoring by the MDS nurse, but the incident demonstrated a failure to adhere to these protocols.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors during their review of facility practices and records.
Dishwasher Not Maintained at Required Sanitization Temperatures
Penalty
Summary
The facility failed to maintain the kitchen dishwasher in safe operating condition, as required by the manufacturer's recommendations. Observations and interviews revealed that the dishwasher did not reach the minimum recommended wash and sanitize temperatures of 120 degrees Fahrenheit, with recorded wash temperatures as low as 95 degrees and final rinse temperatures sometimes below 120 degrees. Dietary staff, including a dietary aide and the Dietary Manager, confirmed the machine was not reaching the correct temperature, and the issue was observed over multiple cycles. The posted manufacturer instructions indicated that water should be at least 120 degrees, and staff were instructed to report if it was lower, but this was not consistently done. Further review of the dish machine logbook for the month showed repeated instances where the wash and rinse temperatures were below the recommended levels. The dietary aide stated he did not report the issue because he was unaware it needed to be reported, and the Administrator was unsure about the reason for the temperature adjustment, noting the machine had recently been replaced. No policy on dish sanitization was provided when requested by the surveyor.
Failure to Post Oxygen Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care were provided with appropriate safety measures, specifically the posting of oxygen in use signage on the doorways of two residents who were receiving oxygen therapy. Both residents had documented diagnoses of chronic obstructive pulmonary disease (COPD) and physician orders for oxygen administration via nasal cannula. Observations confirmed that each resident was using oxygen, either through a concentrator or portable tank, and that no oxygen signage was posted outside their respective rooms as required by facility policy. Interviews with staff, including an LVN and the DON, confirmed that it was the facility's expectation to have oxygen signs posted on the doors of rooms where oxygen was in use. The DON acknowledged the absence of the signs and stated that they are typically posted for resident safety, suggesting the signs may have fallen off. The facility's policy on oxygen administration also specified the need for appropriate oxygen signage. The lack of signage was observed during multiple walkthroughs and confirmed by both staff and administrative personnel.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were stored securely in accordance with professional standards. Specifically, the nurse treatment cart was found unlocked, unattended, and unsupervised, containing various wound care medications such as miconazole antifungal powder, collagenase enzyme paste, hypochlorous acid solution, and other wound care products. Interviews with two LVNs confirmed that the cart was left unlocked, with one stating the keys were left by the nurse’s station and acknowledging that the cart should have been locked. The facility’s own policy requires all medications to be stored in locked compartments, but this was not followed in these instances. Additionally, a medication cart on the 400 hall was observed unlocked and unattended while a nurse was administering medications in a resident’s room. The nurse admitted the cart should have been locked when unattended. The Director of Nursing confirmed the expectation that medication carts be locked when not in use and acknowledged the risk if this protocol is not followed. These observations and staff interviews demonstrate a failure to adhere to the facility’s medication storage policy.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Disinfect Glucometer Between Residents
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding the disinfection of glucometers between resident uses. During an observation, an LVN used a glucometer to assess the blood sugar level of one resident and, without disinfecting the device, proceeded to use the same glucometer on another resident. The LVN performed hand hygiene but did not disinfect the glucometer before attempting to assess the second resident. The state surveyor intervened before the second resident's blood was drawn. During interviews, the LVN acknowledged the failure to disinfect the glucometer and recognized the risk of cross contamination. The DON confirmed that the facility's expectation was for staff to disinfect glucometers between each resident use with an approved chemical wipe for bloodborne pathogens. Record reviews showed that both residents involved had diagnoses including diabetes and sepsis, and both were receiving insulin injections per physician orders. The facility's policy on glucometer disinfection required cleaning and disinfecting the devices after each use and according to the manufacturer's instructions for multi-resident use. The deficiency was identified through observations, interviews, and record reviews, which confirmed that the facility did not follow its own written standards, policies, and procedures for infection control regarding glucometer disinfection.
Some of the Latest Corrective Actions taken by Facilities in Texas
- Implemented mandatory in-service training on abuse, neglect, and reporting procedures for all staff before they may work (K - F0600 - TX)
- Educated the Director of Nursing and nursing staff on the Neurological Assessment Policy, including requirements for neuro checks after unwitnessed falls or head injuries (K - F0600 - TX)
- Established monthly QAPI meetings to monitor completion of required in-services on abuse, neglect, and reporting (K - F0600 - TX)
- Required the Administrator to verify that all new hires complete mandated in-services prior to their first shift (K - F0600 - TX)
- Adopted a policy to suspend or terminate any staff member suspected of abuse or neglect pending investigation outcomes (K - F0600 - TX)
Failure to Monitor and Communicate After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to protect a resident from neglect following an unwitnessed fall that resulted in a head injury. The resident, who had severe cognitive impairment and was on the anticoagulant Eliquis, was identified as having a cut on the right side of his head after the fall. Despite the presence of a head injury and the resident's high risk for bleeding due to anticoagulant therapy, staff did not communicate the injury to the nurse in a timely manner, nor did they initiate neurological assessments as required by facility policy. Multiple staff members observed the injury and noted changes in the resident's behavior, such as increased lethargy, but did not report these findings or escalate care appropriately. The nurse who eventually assessed the resident performed only a single neurological check and, despite being aware of the resident's anticoagulant use, did not initiate ongoing neuro checks or communicate the incident to other staff or the physician as required. The incident report was completed as a late entry, and there was no documentation of physician notification or of the resident's change in condition. Facility policies required neuro checks for 72 hours after any unwitnessed fall or head injury, especially for residents on anticoagulants, but these protocols were not followed. The resident's condition deteriorated over the following days, with staff and family members observing increased lethargy and a lack of normal behavior. The resident was eventually found unresponsive with blood around the mouth and was sent to the hospital, where a large subdural hematoma was diagnosed. The resident subsequently passed away due to a nonsurvivable head bleed. Interviews with staff and review of records confirmed that required assessments, monitoring, and communication were not performed according to policy, resulting in neglect.
Removal Plan
- The facility RN B was suspended immediately pending investigation by the administrator.
- All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures by the Director of Nursing. For those who cannot be reached by phone will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- The director of nursing was educated on the neurological policy by the VP of Clinical Services. The Director of Nurses was educated by the VP of Clinical Operations, related to the policy stating that neuro checks will be initiated upon any unwitnessed fall or fall with head injury, to continue unless otherwise indicated.
- All current nursing staff were in-serviced on documentation of Unwitnessed falls and Neuro Check Policy by the Director of Nursing. For those who cannot be reached by phone, will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- RN B will complete all in-services 1:1 with the DON if allowed to return work with residents.
- The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect is completed by all staff members. Completion will be reviewed at monthly QAPI meetings.
- DON is responsible for ensuring that all assigned nursing in-service are completed. For those who cannot be reached by phone, will not return to work without receiving this in-service prior to anyone working. The administrator will review any new staff to ensure in-services are completed, prior to their first shift on the floor.
- DON reviewed all other residents on anticoagulants for falls and neuro check documentation. No further injuries were noted on any residents.
- Social worker completed Safe Surveys on the other interviewable residents to ensure they feel safe and free from abuse and neglect. No residents reported signs of Abuse or Neglect.
- Any staff member suspected of committing abuse/neglect will be suspended immediately and/or terminated depending on the outcome of the investigation.
- Staff who fail to report suspected abuse and change in condition will be educated on the significance of reporting time and disciplined accordingly.
- DON/Designee will conduct random questioning on 3 staff members daily for 4 weeks for staff to ensure they are understanding and retaining the education on abuse and neglect and reporting procedures.
- Results from random staff questioning will be reviewed during the monthly QAPI meetings with DON, Administrator, and Medical Director. Any incorrect answers will be corrected immediately. Progress will also be monitored during weekly Committee Meetings and Medical Director will be notified of all progress.
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