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Based on interview and record review the facility failed to fully investigate allegations of neglect. (citing Patient # 7)

The facility policies related to abuse did not identify or define neglect as a form of abuse.

*Neglect (defined by CMS) : Neglect is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Findings include:

TX 00285100

Record review of intake # TX 00285100 narrative revealed two (2) allegations of neglect :

Allegation # 1:

Family members found Patient # 7 "...flat on her back with two gowns tied tightly around her neck and a flannel shirt under her gown.. She was lying in a crooked position with tears streaming down her face." Patient # 7 told her family she asked a nurse for help during the night. "The nurse said she would find 2 attendees to help but they never came."

Complainant stated in the complaint narrative she immediately reported this incident to the administrator.

Allegation # 2:

On 12-20-2016, family found Patient # 7 "lying flat in bed...gown pulled up..with two adult diapers and a pad.." Complainant stated "the diaper was full of feces (fresh & dried) and Patient # 7 had feces under her fingernails." Further allegation was the door was left wide open, patient uncovered and cold. Complainant stated Patient # 7 asked for help during the night and said a young girl left her uncovered and lying flat. Patient # 7 told her family "she kept having to go on herself during the night.."

Complainant stated Patient # 7 had recent brain surgery, a stroke, and had a feeding tube. In addition, Patient # 7 was not to lay flat, as she had swallowing issues related to her stroke and could choke. Complainant stated she requested an urgent and immediate transfer to another facility.

Facility Documentation/Interviews:

Review of facility documentation of complaint, dated 12-20-16, revealed family of Patient # 7 reported when they arrived shortly after 7 a.m. that they found mother "uncared for" lying flat in bed and soiled with stool. Family alleged Patient # 7 was left that way all night long. It was documented that staff met with family at bedside and family was told the following actions would be taken: documentation would be reviewed; call light response times checked; and follow-up with staff who cared for the patient would be done.

Interview on 06-07-18 at 1:15 p.m. with Chief Executive Officer (CEO) # 1 she stated "One of Patient # 7's daughter's said her mother was left soiled for many hours. We did not find this to be the case. After discussion, they agreed to stay. We had addressed their issues." CEO # 1 stated the facility had the capability to run reports that detailed call light response.

Facility was unable to produce documentation of an investigation. There were no documented interviews with staff who cared for Patient # 7; no analysis of call light response; no record review of care provided; no review of adequacy of staffing or and staff training.

Record review of facility policy titled "Electronic Event Reporting (ERS)",dated 4/19/2018, read:"...Procedures:..The Quality Committee has delegated the task of investigation of adverse events to the Director of Quality Risk (DQR), and the DQR may designate individuals to assists with these investigations as needed..."

Record review of facility policy titled "Allegations of Abuse," dated 4/4/2018, failed to include "neglect" as a form of abuse. In addition, the policy included but failed to define the following: "physical abuse; sexual abuse; molestation; harassment."

Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) supervised the care of 2 of 6 sampled patients. Nursing failed to ensure physician orders for fall precautions were implemented (Patients # 12 & 13).

Findings include:

Patient #12:

Record review of clinical record of patient #12 revealed she was a 91 year old female admitted to the facility on 5/26/18 for rehabilitation after she broke her left femur (leg bone) and needed an Open Reduction Internal Fixation procedure. Further review of patient #12's clinical records revealed a history & physical from Dr.#12, which stated patient has severe weakness in both legs. There was a physician's order dated 5/27/18 that read "fall precautions".

Observation on 6/7/18 at 9:00 am of patient # 12 revealed she was wearing a color coded wristband indicating she was on Fall Risk Precautions, but patient did not have a red leaf placed on her door.

In an interview on 6/7/19 at 9:05 am with staff # 10, she stated that the patient should have had a red leaf on her door.

Patient # 13:

Record review of clinical records for patient # 13 revealed she was an 87 year old female admitted to the facility on 5/31/18 to obtain rehabilitation therapy after she had fallen. Further review of patient's history & physical dated 6/1/18 by Dr. #13, read that the patient also had neuropathy, encephalopathy, and a history of Dementia. Further review of patient's clinical record revealed a physician order dated 5/31/18 that read "fall precautions".

In an interview on 6/7/18 at 9:15 with staff # 9, she stated that patients on fall Risk Precautions should have a red 'falling leaf' placed outside their room doors and also be wearing a yellow or red wristband indicating they were at high risk for falls.

Observation on 6/7/18 at 9:15 am of patient # 13 revealed she was not wearing any color coded wristband, nor did she have a red leaf outside her room door.

In an interview on 6/7/18 and 9:15 am with staff# 9, she stated that the patient should have been wearing a color coded wrist band and also should have had a red leaf outside their door.

Record review of facility policy titled "Fall Prevention 11.46 "(no date) stated that for patients placed on precautions for High Risk for Falls; " .... High Risk...3. Place colored coded wristband on patient to alert all personnel of high fall risk. 4. A red falling leaf will be placed outside patient's door indicating the patient is high risk".

Based on interview and record review, the facility failed to ensure that nursing staff developed and kept current a nursing care plan for 2 of 6 sampled patients (Patients #12 and #13).

Findings include:


Patient #12:

Record review of clinical record of patient #12 revealed she was a 91 year old female admitted to the facility on 5/26/18 for rehabilitation after she broke her left femur (leg bone) and needed an Open Reduction Internal Fixation procedure. Further review of patient #12's clinical records revealed a history & physical from Dr.#12, which stated patient had severe weakness in both legs. There was a physician's order dated 5/27/18 that read "fall precautions". However, there was no evidence that Fall Precautions were addressed in the patient's Nursing Care Plan.

In an interview on 6/7/18 at 10:00 with Charge Nurse-Staff #8, she stated that patient #12 should have had Fall Precautions addressed on their nursing care plans.


Patient #13:

Record review of clinical records for patient #13 revealed she was an 87 year old female admitted to the facility on 5/31/18 to obtain rehabilitation therapy after she had fallen. The patient also had neuropathy, encephalopathy, and a history of Dementia. Further review of patient's clinical record revealed a physician order dated 5/31/18 that read "fall precautions". However, there was no evidence that Fall Precautions were addressed in the patient's Nursing Care Plan.

In an interview on 6/7/18 at 10:00 with Charge Nurse-Staff #8, she stated that patients #13 should have had Fall Precautions addressed in her nursing care plan.

Record review of facility policy titled "Plan of Care-Nursing 11.77 (no date) read "Purpose ... ....2. It is the policy of HealthSouth Rehabilitation Hospital of Cypress to develop an individualized Plan of Care for each patient ... ... ...Guideline: ... ....1. Care is planned to respond to each patient's unique needs ... ....2. Patient care, treatment, and rehabilitation are planned to ensure that they are appropriate to the patient's needs and severity of disease, condition, impairment or disability .....Procedure 1. Assessment, upon admission .....actual and potential problems will be identified and prioritized ... ....5. Documentation ... ...B ... ...The POC (plan of care) will be used consistently throughout the hospitalization ... ...D. Implementation of the plan of care and evaluation will be narratively documented in the Nursing 24 hour flow sheet ....