Durham Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Durham, North Carolina.
- Location
- 411 S Lasalle Street, Durham, North Carolina 27705
- CMS Provider Number
- 345070
- Inspections on file
- 30
- Latest survey
- February 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Durham Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to label medications with resident names, discard expired medications, and store medications according to manufacturer instructions. Insulin pens and compounded omeprazole suspensions were found expired, and latanoprost eye drops were improperly stored. The DON confirmed the need for proper labeling, storage, and disposal of medications.
A resident with cognitive impairment and limited mobility was repeatedly found with their call bell out of reach, preventing them from requesting assistance. Despite being alert and able to communicate, the resident's call bell was tied to the bed rail and often on the floor, as confirmed by staff observations and interviews.
The facility inaccurately coded MDS assessments for three residents, leading to discrepancies in their medical records. A resident with schizophrenia was incorrectly coded for PASRR Level I instead of Level II, and another resident was wrongly noted as receiving insulin instead of hypoglycemic medication. Additionally, a resident was inaccurately recorded as receiving antianxiety medication. These errors were acknowledged by the staff involved.
A facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. The resident, admitted with hypoxia, was on continuous oxygen therapy at 2 L/min via nasal cannula. Observations confirmed the absence of signage, and staff interviews revealed that the responsibility for posting signage was with the admitting nurse or Unit Manager, which was missed.
A resident with a history of stroke reported numbness and pain in his left side to nurse aides, but the nursing staff failed to assess the condition or notify the physician. The resident's symptoms worsened, leading to a delayed diagnosis of an ischemic stroke. The lack of timely assessment and communication resulted in the resident being outside the treatment window for Alteplase, a stroke medication.
A facility failed to implement necessary medical interventions for a resident with untreated sleep apnea, leading to severe health decline and hospitalization. Despite physician orders for a CPAP machine and consultations, these were not executed due to transportation issues. Another resident with stroke symptoms was not comprehensively assessed, resulting in delayed treatment and critical care admission. These deficiencies highlight the facility's failure to respond to significant changes in residents' conditions.
The facility failed to conduct annual performance reviews for five nurse aides, as required by regulations. The Director of Nursing and Staff Development Coordinator, both recently hired, were unaware of the facility's process for maintaining nurse aide competency skills training and performance reviews. The Administrator confirmed that due to turnover in the Staff Development Coordinator position, there was no evidence of completed training and education, resulting in a lack of documentation for the required annual performance reviews.
A resident with obstructive sleep apnea did not receive a Pulmonary consultation or a CPAP machine due to transportation issues, despite physician orders. The resident also missed a Neurology consultation for migraines. Facility staff were aware of the transportation difficulties but did not resolve them, leading to missed critical medical appointments.
The facility was cited for deficiencies in food safety and equipment maintenance. A dietary aide handled food without gloves or facial hair covering, and the kitchen was not clean. Food items in the walk-in cooler were not properly labeled, and the dish machine failed to reach the required temperature. Insulated dome lids were stored wet. The dietary supervisor and maintenance director acknowledged these issues.
The facility failed to maintain a clean environment, with growth buildup found in and on an ice machine. Observations revealed blackish-brown spots and pinkish/black matter on the machine, and blackish matter, light beige growths, and yellow material on the floor and molding. The Maintenance Director was unaware of the issue, and the Administrator was uncertain about the deep clean schedule.
A privacy breach occurred when a medication cart laptop was left unattended, displaying resident health information in a public area. Nurse #4 admitted the oversight, and both the DON and Administrator confirmed the need to lock the laptop screen when unattended.
A medication cart in Zone 1 was found unlocked and unattended, with staff and residents passing by. Nurse #3, who was administering evening medications, later locked the cart. The cart contained resident medications, including insulin pens and medicated ointments. The DON confirmed that medication carts should be locked when unattended.
A resident with obstructive sleep apnea did not receive a CPAP machine as documented by a physician. The resident reported never having the machine or seeing a pulmonologist, despite the physician's note indicating CPAP use. The DON confirmed the resident never had the machine, and the facility failed to monitor the physician's documentation.
A resident did not receive their prescribed Liraglutide due to the facility's failure to notify the pharmacy of the missing medication. Despite procedures in place, nursing staff did not contact the pharmacy, leading to missed doses. The physician and administrator highlighted the lack of communication and questioned the pharmacy's delivery system.
A resident with diabetes and kidney failure did not receive prescribed medications due to unavailability. Nurses failed to administer insulin and Liraglutide as ordered, and did not consistently notify the physician about the medication shortages. The DON and physician confirmed that staff should have followed orders and communicated medication issues.
A resident with cerebral palsy and contractures sustained a mildly displaced left medial malleolus fracture during an unsafe transfer using a sit-to-stand lift. The resident's ankle got caught in the wheelchair, leading to significant pain and the need for emergency room evaluation. The facility staff followed protocols for pain management and further evaluation, and the resident's care plan was updated to use a mechanical lift for transfers.
The facility's QAA committee failed to develop and implement an effective plan to prevent accidents, resulting in repeated unsafe transfer incidents. One resident sustained a fracture during a sit-to-stand lift transfer, and another incident involved a mechanical lift tipping, requiring staff intervention to prevent injury.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label medications with the minimum required information, including the resident's name, on one of the medication carts observed. During an observation, an in-use prefilled pen of Insulin Glargine-yfgn was found on the medication cart without a resident's name, and the expiration date indicated it had expired 11 days prior. Additionally, an in-use prefilled pen of Insulin Lispro for a resident was found with an expiration date that had passed 17 days before the observation. There was no indication of when these insulin pens were dispensed or put into use. The facility also failed to discard expired medications on two medication carts and in the medication storeroom. In the medication storeroom, an opened vial of Novolin R insulin was stored without a date indicating when it was opened, and it had been dispensed 111 days prior. Two bottles of compounded omeprazole suspension were found with expiration dates that had passed 37 and 2 days before the observation, respectively. These expired medications were confirmed by the nursing staff during the observation. Furthermore, medications were not stored according to the manufacturer's instructions on one of the medication carts. An unopened bottle of latanoprost eye drops, which should be refrigerated, was found stored on the medication cart. The Director of Nursing confirmed that medications needed to be labeled correctly, stored as instructed, and expired medications should be discarded or returned to the pharmacy. The facility's unit managers were expected to perform weekly checks to ensure compliance with these requirements.
Resident's Call Bell Out of Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to request staff assistance. The resident, who was moderately cognitively impaired and dependent on staff for all activities of daily living, was observed multiple times with the call bell out of reach. The resident had impairments in both upper and lower extremities, requiring substantial to maximum assistance for movement. Despite being alert and able to communicate needs, the resident was unable to reach the call bell, which was tied to the bed rail and often found on the floor. Observations and interviews with staff, including a nurse and the Director of Nursing (DON), confirmed that the call bell was not within the resident's reach on several occasions. The DON acknowledged the issue and repositioned the call bell within reach during an observation. Staff interviews revealed that the resident was alert, oriented, and able to use the call bell, but the staff had not noticed it was out of reach. The resident required total assistance for care and could not reposition independently, highlighting the importance of having the call bell accessible.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #23, who was diagnosed with major depressive disorder and schizophrenia, was inaccurately coded as having a PASRR Level I status instead of Level II, despite her care plan correctly reflecting the Level II status. Additionally, her MDS assessment incorrectly indicated that she received an insulin injection, while her records showed she was on hypoglycemic medications like Ozempic and glipizide, with no insulin administered during the specified period. Resident #52, diagnosed with schizoaffective disorder, was incorrectly coded as having received an antianxiety medication during the 7-day lookback period on her MDS assessment. However, her medical records and interviews with staff confirmed that she did not receive any antianxiety medication during that time. This discrepancy was acknowledged by the MDS nurse responsible for the assessment. Resident #4, with a diagnosis of type 2 diabetes mellitus, was inaccurately coded as receiving insulin on her MDS assessment. In reality, she was receiving Ozempic for weight management, not insulin. The MDS Coordinator misinterpreted the drug classification, leading to the error. Interviews with the resident and nursing staff confirmed that she was not on insulin, highlighting a misunderstanding of the medication classification system used by the facility.
Failure to Post Oxygen Signage for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. This deficiency was identified for a resident who was admitted with a diagnosis of hypoxia and had a physician's order for oxygen supplementation at 2 liters per minute via nasal cannula. Observations on multiple occasions revealed that the resident was receiving continuous oxygen therapy, but there was no signage outside the room to indicate this. The absence of signage was noted during observations on different days and times. Interviews with facility staff, including a nurse and the Director of Nursing (DON), confirmed that the responsibility for placing oxygen signage on a resident's door fell to the admitting nurse or the Unit Manager. The DON acknowledged that the signage was missed by the nurses, indicating a lapse in the facility's protocol for ensuring safety measures were in place for residents receiving oxygen therapy.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician and responsible party of changes in condition for a resident with a history of stroke and intact cognition. On the evening of 10/21/24, the resident reported pain and numbness in his left arm and leg to a nurse aide, who informed the nurse. However, the nurse did not assess the resident or notify the physician. The resident continued to experience symptoms, including an inability to feel his left side, which he reported to another nurse aide on the next shift. Again, the nurse was informed but did not conduct an assessment or notify the physician. The situation escalated when the resident was found by a unit manager on the morning of 10/22/24 with slurred speech and paralysis on his left side. The nurse practitioner assessed the resident and arranged for his transfer to the emergency department, where he was diagnosed with an ischemic stroke. The delay in assessment and notification resulted in the resident being outside the window for administering Alteplase, a medication used to treat ischemic strokes. Interviews with staff revealed a lack of communication and failure to follow protocol in assessing and reporting the resident's change in condition. The nursing staff did not document any progress notes regarding the resident's condition on 10/21/24 or 10/22/24 until after the unit manager's assessment. This deficiency in communication and documentation contributed to the delay in the resident receiving timely medical intervention.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance.
- An audit to determine if any residents had reported any new change in condition that was not reported to the healthcare provider by a licensed nurse of residents with a brief interview for mental status (BIMS) score of 13 or higher was completed by the Administrator.
- An audit was completed by the Director of Nursing of progress notes to ensure that anyone reporting a change of condition had provider notification.
- The Director of Nursing questioned all of the licensed nurses regarding knowledge of any residents having had a change in condition that deviated from their baseline and did not have healthcare provider notification.
- The Director of Nursing or Staff Development Coordinator interviewed all nursing assistants regarding knowledge of any residents having change of conditions that were not reported to the healthcare provider.
- The Director of Nursing initiated education to all licensed nurses to complete a clinical assessment of a minimum vital signs and pertinent body systems once notified of a change in condition.
- Education included any changes reported by nursing assistants.
- Any licensed nurse that has not been educated will be taken off the schedule until the education has been received.
- All new hires will be educated by the Director of Nursing during orientation.
- The Regional Director of Clinical Services educated the Administrator, The Director of Nursing, Staff Development Coordinator, and The Human Resource Director on the orientation process for nursing staff.
- The Director of Nursing/Staff Development Coordinator re-educated all nursing assistants on change in condition of residents to include recognizing signs and symptoms of a stroke.
- Any nursing assistant that has not received the education will be taken off the schedule until the education has been received.
Failure to Implement Medical Orders and Assess Changes in Condition
Penalty
Summary
The facility failed to comprehensively assess and implement necessary medical interventions for a resident with untreated obstructive sleep apnea, leading to a significant decline in the resident's health. Despite physician orders for a CPAP machine, a pulmonology consultation, a neurology consultation, and an x-ray, these were not executed due to transportation issues and lack of follow-through. The resident experienced periodic abdominal pain, changes in mental status, and migraines over six months, with elevated CO2 levels noted in lab results. On one occasion, the resident was excessively sleepy, difficult to rouse, and had no oral intake, leading to an emergency medical intervention where the resident was found to be hypoxic and in a comatose state. Another resident with a history of stroke reported numbness and pain in the left arm and leg, which was not comprehensively assessed by the nursing staff. The resident's condition worsened overnight, and by the next morning, the resident exhibited symptoms of a stroke, including slurred speech and vision changes. The resident was eventually transferred to the emergency department, diagnosed with a cerebral vascular accident, and admitted to the critical care stroke unit. The delay in assessment and intervention resulted in the resident being outside the window for effective stroke treatment. These deficiencies highlight the facility's failure to identify and respond to significant changes in residents' conditions, leading to immediate jeopardy situations. The lack of comprehensive assessments and timely medical interventions for both residents resulted in severe health outcomes, including hospitalization and critical care admissions.
Removal Plan
- The facility failed to comprehensively assess a resident who had untreated obstructive sleep apnea to determine the root cause of periodic abdominal pain, change in mental status, and migraines in conjunction with elevated CO2 levels on labs.
- The facility also failed to implement physician's orders for a CPAP, pulmonology consultation, neurology consultation, x-rays and ultrasound.
- The nurse practitioner performed a comprehensive assessment and recommended that she be transferred to hospital.
- Resident was comprehensively assessed by the nurse practitioner who recommended she go to the hospital.
- Resident was diagnosed in the hospital with altered mental status, acute respiratory failure, acute kidney injury, transaminitis, and migraines.
- Resident was placed on a BIPAP and admitted to an intensive care unit.
- She received IV Lasix and supplemental oxygen.
- An Ultrasound was done due to transaminitis which demonstrated steatosis.
- Resident received an order for Fioricet for migraines.
- Resident's pulmonary and neurology consultations were discontinued upon discharge to hospital.
- Upon return to the facility, Resident did not have any new orders for pulmonology consultation or follow up as she currently has BIPAP in place.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for five nurse aides, as required by healthcare regulations. The employee files for these nurse aides did not contain the necessary performance review documents for the years 2023 and 2024. The Director of Nursing, who was hired in May 2024, was unaware of the facility's process for maintaining nurse aide competency skills training and performance reviews. She could not provide evidence of any training done prior to her employment. Similarly, the Staff Development Coordinator, hired in August 2024, was also unaware of the facility's process and had not started reviewing employee training files or conducting annual performance evaluations. The Administrator confirmed that nurse aides' skills assessments and competencies should be completed at hire and annually, along with a performance review. However, due to turnover in the Staff Development Coordinator position, there was no evidence that the required training and education were completed and documented. The facility was unable to provide documentation indicating that the nurse aides' annual performance reviews were completed, highlighting a lapse in maintaining proper records and ensuring compliance with mandatory requirements.
Failure to Provide Necessary Medical Consultations and Equipment
Penalty
Summary
The facility failed to ensure that a resident with obstructive sleep apnea received a necessary Pulmonary consultation and a CPAP machine, as ordered by the physician. The initial order for a Pulmonary consultation and CPAP machine was made in April 2024, and a subsequent order was made in May 2024. However, the resident never attended the consultation or received the CPAP machine due to transportation issues. The resident was also ordered to attend a Neurology consultation in August 2024 for constant migraines, but this appointment was also missed due to the same transportation difficulties. The resident, who was admitted with multiple diagnoses including tachycardia, asthma, morbid obesity, and obstructive sleep apnea, did not have a CPAP machine upon admission. The resident's medical record showed no evidence of receiving the CPAP machine or attending the required consultations. Interviews with the physicians, transport staff, and the resident confirmed the lack of follow-through on these medical orders. The transport staff indicated that the resident's size required non-emergency stretcher transport, which was difficult to arrange due to the transport company's availability. The facility's staff, including the Unit Manager, Nurse Practitioner, and Director of Nursing, were aware of the transportation issues but did not resolve them, resulting in the resident missing critical medical appointments. The resident reported experiencing excessive sleepiness, memory issues, headaches, and abdominal pain over the past six months, which were not addressed due to the missed consultations. The facility's administrator acknowledged the transportation issues but did not provide comments on the lack of follow-through with the resident's appointments.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility was found to have several deficiencies in its food service operations. Observations revealed that a dietary aide was handling food without wearing gloves or a facial hair covering, despite having facial hair. The dietary supervisor confirmed that facial hair coverings and gloves should be used during food preparation. Additionally, the kitchen environment was not maintained in a clean state, with the 3-compartment sink heavily soiled and containing food debris, a greasy substance, and a deceased insect. The maintenance director acknowledged the need for repairs in the dishwashing area, where decaying wooden material was observed. Further issues were identified in the walk-in cooler, where food items such as unshelled hard-cooked eggs and an opened jar of grape jelly were found without proper labeling or dating. The dietary supervisor admitted responsibility for checking the cooler daily but failed to notice these items. The dish machine used for cleaning dishware was also problematic, as it was not reaching the required minimum temperature of 120 degrees Fahrenheit during wash and rinse cycles. The dietary aide operating the machine did not consistently check the temperature, and the dietary supervisor had to contact the vendor for a service call. Lastly, the facility failed to ensure that insulated dome lids and bases were dry before being stored. A dietary aide admitted to rushing and not allowing the items to dry properly. The dietary supervisor and administrator both acknowledged that items should be properly dried before storage. These deficiencies highlight lapses in food safety practices and equipment maintenance within the facility.
Unsanitary Conditions in Ice Machine
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by the presence of growth buildup in and on one of the two ice machines observed. During an inspection, blackish-brown spots were found on the external facing of the ice machine, and pinkish/black colored matter was observed on the internal ceiling and metal lip of the machine. Additionally, the floor and corner molding behind the ice machine exhibited blackish matter, light beige puffy growths, and yellow matted stringy material. The Maintenance Director was unaware of the ice machine's condition and stated that the machines were cleaned quarterly. He had not received any concerns from staff regarding mold in the ice machine. The Administrator mentioned that ice machines were checked weekly by staff and maintenance, but was uncertain about the deep clean schedule for the machines.
Privacy Breach of Resident Health Information
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical records when a medication cart laptop was left unattended with resident health information exposed. This incident occurred with one of the four medication carts, specifically the Zone 1 medication cart. During an observation, the laptop was found displaying personal health information, including names, medications, and diagnoses, in an area accessible and visible to the public. Staff and residents were observed passing by the medication cart during this time. Nurse #4, responsible for the medication cart, acknowledged in an interview that she should have closed or locked the laptop screen to prevent exposure of resident information. The Director of Nursing (DON) and the Administrator both confirmed in their interviews that the laptop screen should have been locked before leaving the medication cart unattended.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to secure resident medications in an unattended medication cart, specifically the Zone 1 medication cart. On the specified date and time, the medication cart was observed to be unlocked and unattended, with the locking mechanism in the unlocked position. During this period, staff and residents were seen passing by the unsecured cart. Nurse #3 was later observed approaching the cart from a resident's room and subsequently locking it. In an interview, Nurse #3 acknowledged that the cart should have been locked when not attended. The cart contained various resident medications, including insulin pens, medicated ointments, and eye drops. The Director of Nursing confirmed that medication carts should be locked when not attended by staff.
Failure to Provide CPAP Machine for Resident with Sleep Apnea
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident regarding the use of a Continuous Positive Airway Pressure (CPAP) machine. The resident, who was admitted with multiple diagnoses including obstructive sleep apnea, was documented in the quarterly Minimum Data Set (MDS) as not having a CPAP machine. However, a physician's note dated June 19, 2024, indicated that the resident was to be initiated on CPAP settings and was stable to continue using the CPAP machine at night. Despite this, the resident reported never having received a CPAP machine or having seen a pulmonologist, which was necessary to obtain the machine. Interviews with the physician and the Director of Nursing (DON) revealed a lack of communication and monitoring of the physician's documentation. The physician was under the impression that the resident had received the CPAP machine, while the DON confirmed that the resident never had a CPAP machine prior to her hospitalization. The facility did not review or monitor the physician's documentation, leading to the oversight that the resident did not receive the necessary equipment for her obstructive sleep apnea.
Failure to Notify Pharmacy of Missing Insulin
Penalty
Summary
The facility failed to notify the pharmacy of missing insulin for a resident, leading to the resident not receiving their prescribed Liraglutide, an anti-diabetic medication, on multiple occasions. The physician's order required the administration of Liraglutide subcutaneously once a day, but the medication was not administered on specific dates in July 2024 due to it being on hold. The Medication Administration Record (MAR) indicated the medication was unavailable, yet there was no documentation of efforts to obtain it from the pharmacy. Interviews with nursing staff revealed a lack of communication with the pharmacy regarding the missing medication. The Director of Nursing (DON) and the consulting pharmacist confirmed that the facility had procedures for notifying the pharmacy when medications were low or unavailable, but these procedures were not followed. The physician expressed concern over not being informed about the medication's unavailability and questioned why the pharmacy did not automatically deliver the medication. The administrator also acknowledged that nursing staff should have contacted the pharmacy to obtain the medication for administration.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to follow physician orders for a resident with type 2 diabetes and kidney failure, leading to significant medication errors. The resident did not receive the prescribed insulin, Tresiba FlexTouch, on a specific date because the medication was not available. Nurse #2, who was responsible for administering the medication, realized the absence of insulin during her shift and notified the Director of Nursing (DON), who then contacted the pharmacy. However, there was no documentation of the insulin being administered on that day. Additionally, the resident did not receive another prescribed medication, Liraglutide, on multiple occasions. The Medication Administration Record (MAR) indicated that the medication was on hold due to unavailability. Several nurses, including agency nurses, were involved in the administration process but failed to ensure the medication was available or to notify the physician about the unavailability. Interviews with the DON and the physician confirmed that staff should have contacted the physician when medications were not available and should have followed the physician's orders as written.
Resident Injury During Unsafe Transfer
Penalty
Summary
The facility failed to safely transfer a resident using a sit-to-stand lift, resulting in the resident sustaining a mildly displaced left medial malleolus fracture and experiencing significant pain. The resident, who had a history of cerebral palsy, contractures, and previous left knee fusion surgery, was dependent on staff for transfers and other activities of daily living. During the transfer, the resident's ankle got caught in the wheelchair, leading to the injury. The incident was reported by the nurse aide to the assigned nurse, who then assessed the resident and administered pain medication as per physician orders. An X-ray confirmed the fracture, and the resident was sent to the emergency room for further evaluation and treatment, including the application of a CAM boot and prescription of pain medication. The resident was discharged back to the facility the same day. The nurse aide involved in the incident was an agency staff member who worked sporadically at the facility. He did not recall the type of mechanical lift used during the transfer and only realized the resident's leg was caught after the transfer was completed. The nurse aide received in-service training on mechanical lift transfers after the incident. The assigned nurse and the physician were both notified of the incident and took appropriate steps to manage the resident's pain and ensure further evaluation. The Director of Nursing confirmed that the resident required staff assistance for transfers and that the incident occurred during a sit-to-stand lift transfer. The resident's care plan was subsequently updated to reflect the use of a mechanical lift for transfers. The facility's Director of Nursing and Administrator were both aware of the incident and confirmed that the facility followed protocols to ensure the resident's safety. The Director of Nursing stated that the nurse aides were retrained on mechanical lift transfers, and the resident's care plan was updated to reflect the change in transfer method. The Administrator reviewed the interventions put in place and confirmed that they were effective, as no further incidents had occurred.
Repeat Issues with Resident Transfers Highlight QAA Failures
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to self-identify the need for the development and implementation of an effective plan to achieve and sustain compliance in the area of supervision to prevent accidents. This was evidenced by a repeat issue with staff failing to transfer residents safely. Specifically, an incident occurred where a resident was transferred using a sit-to-stand lift, resulting in the resident sustaining a mildly displaced left medial malleolus fracture and experiencing significant pain. Another incident involved a mechanical lift tipping to one side, requiring two staff members to lower the resident to the floor without injury. During an interview, the facility's Administrator stated that the QAA committee was scheduled to meet at least quarterly but typically met about once a month. The Administrator acknowledged that after the first incident, the resident was transferred using a mechanical lift instead of a sit-to-stand lift. However, no performance improvement plan was implemented after the initial incident, as there were no other residents using a sit-to-stand lift in the facility. This lack of a comprehensive plan contributed to the recurrence of unsafe transfer practices, highlighting the facility's inability to sustain an effective QAA program.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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