St. James House of Baytown

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse, including mental, verbal, physical, and sexual abuse, as well as abuse involving the deprivation of goods and services by staff. This deficient practice was identified for one of five residents reviewed for abuse. Specifically, Resident #1 alleged that facility staff physically held his arm down while LVN S removed his personal cell phone without his consent. This deficient practice had the potential to result in psychosocial harm, including mental and verbal abuse, as well as deprivation of services by staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident#1) reviewed for abuse, in that: The facility failed to ensure staff followed the abuse, neglect, and exploitation policy related to reporting, investigating, and responding to allegations of abuse. This failure could place residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving were reported immediately, but not later than 24 hours, to the administrator of the facility for 1 of 5 resident (Resident #1) reviewed for reporting. Resident #1 alleged that facility staff physically held his arm down while LVN S removed his personal cell phone without his consent, and this allegation was not reported to the administrator at the time it occurred. This failure had the potential to delay timely investigation and implementation of protective interventions, which could result in continued abuse, neglect, or misappropriation of resident property.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents were free from any significant medication errors for 1 (Resident #88) of 4 residents reviewed for pharmacy services.-The facility failed to ensure Losartan (a blood pressure (BP) medication given to lower high blood pressure and help protect the kidneys) was administered to Resident #88 per physician order from [DATE] through [DATE]. -The facility failed to ensure accurate reconciliation (a process of comparing and verifying a resident's current list of medications with all prescribed medications to ensure accuracy and safety), of Resident #88's Losartan medication. -MA A administered Losartan 25 mg give 1/2 tablet to equal 12.5mg by mouth daily to Resident #88 and documented they administered Losartan 100 mg give 1 tablet by mouth daily. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 11 residents (Resident #88) whose records were reviewed for accuracy and completeness. MA A administered Losartan 25 mg give 1/2 tablet to equal 12.5mg by mouth daily to Resident #88 and documented they administered Losartan 100 mg give 1 tablet by mouth daily. This failure could place residents at risk for less than therapeutic benefits and/or not receiving ordered medications due to incomplete documentation.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 5 residents (CR#1) reviewed for physician notification. The facility failed to contact the physician for over 5 hours when CR#1 had shortness of breath and was gurgling. After approximately 5 hours, CR #1 was sent to the hospital via emergency transport and was admitted with Pneumonia, Acute Kidney Failure, and Septic Shock and expired 2 days later. An Immediate Jeopardy (IJ) situation was identified on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 3 residents (Residents #1 and #2) reviewed for respiratory care. 1. The facility failed to ensure the filter in Resident #1's oxygen concentrator was not dirty. 2. The facility failed to ensure Resident #1's portable oxygen cylinder was not empty while in use. 3. The facility failed to ensure Resident #2's oxygen cannula positioned in her nose for 2 hours. These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #20) of 6 residents reviewed for quality of care in that: The facility failed to ensure Resident #20 received a weekly skin assessment by a licensed nurse between 12/27/22 - 6/26/24 in accordance with the facility policy and care plan. This failure could place residents at risk of unidentified skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: -Food items were found in the kitchen with expired and beyond the use by date. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.

Inspectors wroteBased on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.