Sunrise Home Health Services

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient’s right to be free from neglect by an agency employee for one of one patient (Patient 1) in that the OT failed to provide services necessary to avoid physical harm during a visit. This failure resulted in Patient 1 falling during an OT visit requiring EMS transportation to an emergency room with injury, increased pain and a decline in ambulation. Findings included: Record review of Texas Unified Licensing Information Portal ((a database utilized by the state to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and Hospice agencies for the State of Texas) included a self-reported incident (Intake 1003861) in which the Adm/DON reported to the Health and Human Services Commission Complaint and Incident Intake on 04/16/2025. The report included an allegation of Neglect of Patient 1 by OT. The report read in part, “… During OT session on 04/15/2025, [Patient 1] was ambulating using RW around to the other side of her bed from recliner to address bed mobility… OT had a hold of patient’s gait belt, (a safety device used to help someone move, such as from a bed to a chair. The belt is also used to help hold someone up while walking, to provide support and prevent a fall)and was walking with patient. When close to bed, OT moved pillows to allow room for patient to sit down, and noticed what appeared to be large wet spots on the sheets at the head of the bed under pillows on clean and made bed. OT turned, while still having a hand on patient, to see if area was wet before having patient sit and lay down. Patient then said “I’m going down.” OT quickly turned towards patient who was no longer holding on to her walker and began falling backwards. OT unable to keep patient from landing on her bottom on the floor… Patient… complained of pain in lower back… When EMTs assessed patient’s cardiac rhythm, they reported that patient was having Ventricular Trigeminy (abnormal heart rhythm)… Patient does not have a history of this… Patient was taken to [Hospital]… Patient was diagnosed with compression fracture of back (broken bone in the spine) in the ER… returned home on same day… Immediate action taken to protect client Reviewed proper transfer protocols with OT…” Record review of the Agency’s complaint log revealed a 2-page document created on 04/17/2025 that was signed by the Adm/DON and titled, “Patient Fall Log” regarding Patient 1 and OT that read in part, “… Fall occurrence date 04/15/2025… The patient fell while being assisted or in the presence of an agency staff member, and the agency staff member was unable to prevent the fall… Agency Staff Member [OT]… Injuries… Type: Major Injury… Compression fracture found… Spoke with [FM] – She states she is disappointed and would like new OT. She reports her family member is very tiny and easy “to catch” if unsteady. She does not believe OT had her hand on gait belt …” Record review of Patient 1’s electronic health record included a plan of care dated 03/06/2025-05/04/2025 with a start of care date of 03/06/2025 that was digitally signed by RN A on 03/06/2025 and Doctor A on 03/26/2025. The plan of care included Patient 1 was born on 07/17/1937, resided in an assisted living facility and had a diagnosis of osteoporosis (a disease that causes bones to become weak and brittle), pain, anxiety, kidney disease, and a history of falling. The plan of care included orders for the nurse to visit once a week for one week, twice a week for two weeks, the once a week for one week and orders for OT and PT to visit twice a week for four weeks. The plan of care read in part, “… Risk Factors: History of falls (2 or more falls - or any fall with an injury - in the past 12 months). Multiple hospitalizations (2 or more) in the past 6 months. Multiple emergency department visits (2 or more) in the past 6 months. Decline in mental, emotional, or behavioral status in the past 3 months… Currently reports exhaustion… At Risk for Falls, S/P Inpatient discharge for fractures of the spine and L ribs… DME… wheelchair. Grab bars… walker. Hospital bed… Safety Measures… Support During Transfer and Ambulation… Safety in ADLs… Functional Limitations… ambulation… Occupational Therapy to provide transfer training from recliner to stand and use RW for functional mobility focused on correct hand and feet placement to address difficulty with postural control with sit… stand transitions… Occupational Therapy to develop and manage a balance program focused on core and back muscle strengthening to address loss of balance during functional mobility tasks… OT Goals… will improve… standing balance… to reduce risk of falls during ADLs…” The record included a 32-page start of care nursing assessment signed and dated by RN on 03/06/2025 that included Patient 1 was 4 foot 8 inches tall and weighed 90 pounds. The assessment read in part, “… past medical history… fractures (broken bones)… falls… anxiety… kyphoplasty 9/18/2024 (a procedure to treat back compression fractures where bone cement is used to stabilize the bone and reduce pain)… ambulation difficulty… poor balance… Able to walk only with the supervision or assistance of another person at all times…” The nursing assessment included: • a Fall Risk Assessment score of 7, where a score of 4 or more is considered at risk for falling; • partial/moderate assistance was required for walking 10 to 150 feet; • a high risk for hospitalization; • pain to the left ribs and lower back rated 4 on a scale of 0-10; • use of an opioid (narcotic) prescription pain medication The record included an OT re-evaluation visit note signed and dated by OT on 04/03/2025 that read in part, “… multiple recent falls resulting in L rib Fxs… Patient is forgetful, and needs cueing for steps in a transition and transfer… impaired balance/gait and pain…” The record included an PT re-evaluation visit note signed and dated by PT on 04/04/2025 that read in part, “… Muscle weakness contributes to increased fall risk w/ transfers, ambulation, ADL’s… Severe debility (weakness), chronic pain, impaired balance, memory/ cognitive deficits contribute to gait impairments… Barrier to progress has been chronic back pain, worse with activity. Although client has made progress, client is still considered a high fall risk, and still requires considerable assistance for safe mobility…” The record included patient care records from Fire Department dated 04/15/2025 that read in part, “… responded to a call for an 87-year old female patient with a chief complaint of a fall from a standing position. Upon arrival… EMS proceeded to the third floor where the patient’s room was located. EMS was greeted by nursing staff and an occupational therapist, who was present at the time of the incident. The occupational therapist reported that while working on mobility exercises with the patient, she momentarily looked away, during which time the patient fell from a standing position… Upon evaluation, the patient… reported significant pain along her spine… The patient was connected to a cardiac monitor to assess vital signs. ECG was performed, revealing bigeminal PVCs (irregular heart rhythm)… The patient was transported to the ambulance, where an IV line was established… the patient continued to report pain. An initial dose of… Fentanyl (potent narcotic) was administered IV. After five minutes, the patient stated the pain had not improved and that the roughness of the ride was exacerbating (increasing) her discomfort. A second dose of… Fentanyl was administered along with… Zofran (anti-nausea medication) IV to prevent nausea…” The record included emergency department medical records from Hospital dated 04/15/2025 that included a diagnosis of a compression fracture of T3 (the third thoracic vertebra, playing a crucial role in the thoracic spine’s structure and function). The record read in part, “… 87-year-old female presents after a ground level fall. She was in the middle of receiving some occupational therapy, she was transferring over when she missed sitting in the appropriate spot causing her to slip off the chair and fall onto her buttocks. There was acute pain in her lower and mid back after that event… She has a chronic spinal issues in his (sic) had kyphoplasty last year… her pain was under reasonable control with a dose of tramadol (narcotic pain medication)... Discussed case with [Doctor B] neurosurgeon, he reviewed imaging. He is suspicious that there is acute (new) fracture at T3…” The active employee roster provided to the surveyor by the Adm/DON on 05/14/2025 at 1:04 PM included OT’s hire date was 02/13/2020. Record review of OT’s personnel record included an active Texas OT license for period ending 10/31/2025. The record included that on 11/12/2024, OT completed mandatory annual agency training which included patient rights and patient abuse, neglect and exploitation. During an interview with OT on 05/15/2025 at 9:46 AM, OT stated: During the OT visit on 04/15/2025, a gait belt was placed on the patient to work on bed mobility and walking. The patient used her RW as the OT and patient approached the bed. The bed appeared to have large wet spots on it so the OT placed her left hand on the patients back and reached to feel if the bed was wet. The OT heard the patient say, “I’m going down.” The OT turned towards the patient who fell backwards onto the floor. An assisted living staff nurse called EMS who transported the patient to the hospital. Prior to the fall, the patient never got out of her recliner unless someone was there to assist. The surveyor asked what the OT could have done differently. The OT stated she could have been more conservative with Patient 1 during the visit but she did not feel Patient 1 had been neglected. The OT stated Patient 1 did not hit her head or lose consciousness when she fell but landed on her bottom. The OT further stated as a result of the fall, Patient 1 was diagnosed with a fractured vertebrae in the Hospital ER. During an interview with the Adm/DON on 05/15/2025 at 2:30 PM, the Adm/DON stated: Patient 1’s FM stated it was the agency’s fault the patient had a setback. Patient 1’s FM considered transferring Patient 1 to hospice after the fall but decided to continue with at home therapy with the agency but requested a different OT for Patient 1. Patient 1 was ambulating approximately 200 feet prior to the fall but was now only able to ambulate 30-35 feet. The Adm/DON further stated knowing Patient 1’s history of falls and compression fractures, the OT should have sat Patient 1 down on the bed and then checked for wet spots. The surveyor asked how Patient 1 was affected by the fall. The Adm/DON stated Patient 1 was transferred to the Hospital ER by EMS due to her injuries that caused increased pain; a decrease in her ability to ambulate the distance that she was previously ambulating and a greater fear of falling. The surveyor read the definition of neglect to the Adm/DON, “Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness” and asked if Patient 1’s rights were violated due to the neglect of the OT. The Adm/DON stated she did not know how to answer the question because she felt the OT was trying to improve Patient 1. The surveyor called Patient 1 on 05/15/2025 at 10:02 AM. Patient 1 declined to speak to the surveyor. The surveyor called FM on 05/15/2025 at 10:06 AM. FM stated she would call the surveyor back but the call was not returned. Agency policy titled, “TX.3 Abuse, Neglect, and Exploitation” with a revision date of 082523 read in part, “… Purpose To identify suspected or alleged victims of abuse, neglect, and exploitation… To protect and promote a patient’s rights, which include the right to be free from verbal, mental, physical, or sexual abuse, neglect and exploitation from an agency employee, contractor or volunteer… Definitions… I. “Adult Neglect” means the failure to provide for one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services… Procedure A… 2. Criteria to identify elder neglect or abuse, physical assault and domestic abuse include… c. Inadequate supervision with resulting effect on ADL provision, e.g., bathing, toileting, food, etc…” Agency policy titled, “RI.1 Patient Bill of Rights and Responsibilities/ Right of the Elderly” with a revision date of 070124 read in part, “Purpose To ensure all patients/patient representative (if any)/legal guardians and Agency staff acknowledge, understand, observe and implement the patient’s rights and responsibilities to protect and promote the patient’s rights… Patient Rights… D. A patient has the right to be free from abuse, neglect, and exploitation by an agency employee, volunteer, or contractor…””