Every finding on record at Falcon South Plains Hospice LP

Based on interview and record review, the agency failed to protect and promote the patient's right to be free from neglect by an agency employee for 1 of 5 (Patient #4) patients reviewed in that: CNA E failed to provide adequate supervision and assistance to patient #4 with the diagnosis of dementia. Specifically, patient #4 was left unattended and unsupervised in the shower which resulted in patient #4 falling in the shower. This failure resulted in patient #4 falling in the shower and placed patient #4 at an increased risk of physical injury. Findings: Record review of Intake #507927 indicated on 05/31/2024 the agencys supervising nurse self-reported an allegation of neglect of patient #4 by CNA E to the Texas Health and Human Services Commission. The intake indicated that patient #4 was left unattended in a shower room by CNA E while she went back to the patients room to get a clean pair of pants. While CNA E was absent the patient fell and was found on the floor by the facility physical therapist. Review of the plan of care for patient #4 dated 05/08/2024 indicated Patient #4 had the diagnosis of Alzheimers disease and dementia. Review of the record for patient #4 revealed a nursing note dated 05/30/2024 indicated that an assessment of patient #4 was performed by RN D and found no significant injuries to patient #4. X-rays were ordered and were determined to be negative for any fractures. Review of the personnel file for CNA E revealed a certificate of completion for a course titled Preventing and Managing Accidents on 05/16/2024. It also revealed a certificate of completion for a course titled Transfers: Assists to and from showers on 05/30/2024 and another certificate of completion of a course titled Preventing and Managing Accidents on 05/30/2024. Review of a written statement by CNA E dated 05/30/2024 revealed in part that CNA E arrived at the facility to shower patient #4, she went to the patients' room to start getting her ready and as she was gathering clean clothes for the patient, the patient reported to CNA E that she had just put clean clothes on that morning. When they arrived at the shower room, CNA E noticed that the patient had dried feces on her pants. She explained to the patient that her pants were dirty, and she needed clean pants. She left the patient standing unattended in the shower room while she went back to the patients room to get her clean pants. When she arrived back to the shower room the facility physical therapist was in the shower room with the patient helping her get up off the floor and sat her in the shower chair. It appeared the patient had fallen on her right side and had two small skin tears on her right elbow and a small red blemish on the top right side of her forehead. Patient #4 complained that her left hip hurt. The facility nurse ordered an x-ray for the right hip and knee and requested CNA E to go ahead and complete patient #4s shower. After the shower was completed, she assisted the patient in drying off and dressing, then the patient ambulated with the assistance of her walker with CNA E by her side back to her room where she sat her in a recliner. An interview with the agency administrator on 07/17/2024 revealed in part that CNA E was brought into the office and was reeducated on the agencys policy of abuse and neglect and the proper procedure for assisting a patient with a shower. Administrator stated that CNA E was remorseful and never wanted any harm to come to the patient. A review of the agencys policy dated 11/29/2019 titled ";Addendum A" Abuse and Neglect read in part, ";...6. Neglect: Lack of basic hygiene, adequate food, or clean and appropriate clothing; Lack of medical aides; person with dementia left unsupervised;..."