North Houston Transitional Care

In the surveyor’s words

From the most serious findings on record at North Houston Transitional Care, in the surveyor’s own words.

• Immediate jeopardy, patternF580Aug 20, 2024

  Based on interview and record review, the facility failed to immediately inform or consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complication) for 1 of 10 residents (CR #1) reviewed for physician notification. LVN A failed to notify or seek clinical guidance from CR #1's physician, or any physician when she observed him in respiratory distress and had an oxygen saturation (blood oxygen level) of 73% upon admission to the facility from a rehabilitation hospital on [DATE]. […]

• Immediate jeopardy, patternF684Aug 20, 2024

  Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (CR #1) reviewed for quality of care. LVN A accepted and retained a new admission from a rehabilitation hospital, CR #1, who was actively in respiratory distress with an oxygen saturation of 73% on [DATE], at approximately 12:30 p.m. and failed to monitor and assess him frequently throughout the rest of her shift (6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m.) after she administered 5L of oxygen and assumed his condition was stable. […]

• Actual harm, isolatedF773Oct 12, 2021

  Based on interview and record review the facility failed promptly notify the ordering physician of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to immediately notify CR #1's physician when a STAT lab was ordered in response to a reported change in condition from the residents' Responsible Party and lab results showed high WBC, BUN, and BUN/Creatinine ratio. The out of range laboratory results were not reported to the physician until 12 hours after they were resulted causing a delay in treatment. […]

• No harm, potential for more than minimal, widespreadF880Aug 21, 2021

  Based on observation, interviews, record review, review of facility policy, and review of Centers for Medicare and Medicaid Services (CMS) QSO 20-39-NH, the facility failed to suspend visitation upon the identification of a new COVID-19 outbreak on 08/20/21 until the first round of testing was complete and no new cases of COVID-19 was identified among staff and residents, and failed to implement the use of full Personal Protective Equipment (PPE- gown , gloves, eye protection, and N95 masks) when providing care for residents who had a potential exposure to a COVID positive staff on 08/20/21, and when providing care for one resident (Resident (R) 14) out of 32 residents on quarantine for COVID-19. […]

• No harm, potential for more than minimal, widespreadF886Aug 21, 2021

  Based on interview, record review, review of policies and procedures, and review of Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH Revised memo, the facility failed to implement outbreak testing of staff and residents to prevent the spread of COVID-19 upon identification that a student nurse tested positive for COVID-19 on 08/10/21. This failure increased the likelihood of COVID-19 transmission to the 62 residents living at the facility. Findings included: Record review of CMS QSO-20-38-NH, issued 08/26/20 and revised on 04/27/21, revealed that upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , regardless of vaccination status, and all staff and residents that tested negative should be… […]