Health inspection·February 8, 2024

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of resident and misappropriation of resident property for one (resident #1) of 2 residents reviewed. Residents Affected - Few Facility staff failed to notify administration when Resident #1 contacted the police notifying them that facility staff was not responding to his call light when he was calling for help because he had fallen from his bed. This failure could place residents at risk of injury or neglect. Findings included: Record review of Resident #1's admission Record dated 2/8/24 revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Muscle Weakness (generalized), Difficulty in walking, not elsewhere classified, Paraplegia (paralysis of the legs and lower body, unspecified, Need for assistance with personal care, Colostomy status (opening for the colon, or large intestine, through the abdomen). Record review of Resident #1's MDS dated [DATE] revealed a BIM score of 15 which indicated his cognition was intact. Record review of Resident #1's MDS Section G dated 9/7/23 revealed; Bed Mobility resident required extensive assistance, 2-person physical assist and for dressing the resident required extensive assistance, 1 person physical assist. Record review of Resident #1's Progress Note dated 9/22/23 revealed a discharge summary. The summary indicated he had been discharged from the facility. Record review of a local Police Department Summary Report revealed an incident called in to the police department on 9/17/23. The report reflected that on 9/17/23 Resident #1 called the police department because he had fallen from his bed and was not able to get assistance from facility staff. The report also reflected that a police officer was sent to investigate and spoke with both Resident #1 and the charge nurse on duty. The report reflected there were no injuries to Resident #1 and he refused medical attention. Record review of Resident #1's progress notes dated 9/17/23, 9/18/23, 9/19/23, revealed no documentation of this incident. Page 1 of 2 676042 676042 02/08/2024 McAllen Transitional Care Center 2109 South K St MC Allen, TX 78503

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of facility's grievance log dated September 2023 indicated a grievance filed on 9/18/23 by Resident #1 on call lights not being answered at the time of incident. During an interview on 2/7/24 at 2:41 pm the local Police Officer said he followed up on an incident that occurred on 9/17/23. He said he reviewed the case and made a referral to HHSC. He said the police were called into the facility by a resident who had fallen from his bed. The Police Officer said there were no injuries reported at the time. The Police Officer said he spoke to the nurse on duty but did not ask him why they did not answer Resident #1's call. Resident #1 was on floor at the time and staff were able to assess and place him in bed. Resident #1 did not want medical attention according to the Police Officer. During an interview on 2/7/24 at 3:28 pm Community Liaison said Resident #1 filed a grievance on 9/18/23 regarding call lights not being answered at night. She said Resident #1 only brought up the issue on call lights, he did not mention anything else. During an interview on 2/8/24 at 1:17 pm the DON said he was never informed by staff that a police officer had gone into the facility on that day. He said nurses were supposed to notify him if the police department was called in to the facility or if a resident had a fall or change in condition. He said staff had been in-serviced on that before. The DON said Resident #1 never mentioned to him that he called police. He said he would have to assess the incident to decide if it was a reportable incident. During an interview on 2/8/24 at 2:09 pm CNA T said she had just started working at the facility and was taking her lunch break when she saw the police in the building. She said she did not know why they were there. During an interview on 2/8/24 at 2:35 pm the Administrator said he was not informed by staff that a police officer had been called to the facility. He said he did not know about the incident. The Administrator said staff were supposed to notify him when the police are called into the facility. Attempts to contact LVN B on 2/7/24 at 2:00pm and on 2/8/24 at 11:00am were unsuccessful. Attempts also made to contact CNA P on 2/7/24 at 2:03pm and again on 2/8/24 at 11:05 am were unsuccessful. Record review of facility's Abuse: Prevention of and Prohibition Against states; Policy & Procedure Freedom from Abuse, Neglect, Exploitation dated; original date: 11/2017, Revision/Review Date(s): 4/2019, 1/2021, 1/2022, 10/2022, 12/2023 states; The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal privacy. H. Reporting/Response 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 676042 Page 2 of 2