Lexington Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, North Carolina.
- Location
- 17 Cornelia Drive, Lexington, North Carolina 27292
- CMS Provider Number
- 345419
- Inspections on file
- 30
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lexington Health Care Center during CMS and state inspections, most recent first.
A resident returned from the smoking area with an odor of marijuana, which was reported by staff and confirmed by a positive drug screen for THC. The resident admitted to using a THC vape obtained from another resident. Despite facility policy requiring law enforcement notification in such cases, the DON and Administrator did not report the incident, citing lack of physical evidence.
A resident identified as a smoker was not assessed for smoking safety upon admission and was not supervised while smoking, despite the care plan indicating supervision was required. The resident kept smoking materials independently, and staff were unaware of the need for supervision or the resident's status, resulting in a failure to follow the facility's smoking policy.
A nurse administered 1 mL (20 mg) of morphine instead of the prescribed 0.25 mL (5 mg) to a resident with advanced cancer and multiple comorbidities, due to unclear physician orders that did not specify the correct volume. The error was identified after administration, and the resident was closely monitored and treated as needed. The incident was attributed to the lack of clarity in the medication order, requiring the nurse to calculate the dose based on concentration, leading to a failure in accurate medication administration.
A resident with metastatic lung cancer received two doses of Narcan and one dose of Lasix following a Nurse Practitioner's verbal orders, but the orders were not entered into the electronic medical record and the medication administrations were not documented on the MAR. Multiple nurses were involved in administering the medications, but confusion over responsibility and issues with the electronic system led to incomplete records.
A nurse aide solicited housing from a cognitively impaired resident, who considered allowing the aide to house-sit his home. The aide attempted to access the resident's home by seeking the key from a neighbor, who refused and alerted the resident's family. The resident, who was vulnerable due to depression, cognitive impairment, and medication use, initially agreed but later changed his mind. The facility failed to recognize and substantiate this as exploitation, and no plan of correction was completed.
A resident was allegedly exploited by a nursing assistant who attempted to gain access to the resident's personal home. Although the incident was reported to law enforcement and investigated internally, the facility failed to notify Adult Protective Services (APS) as required by policy. Staff interviews revealed confusion over reporting responsibilities, and documentation confirmed that APS was not informed of the allegation.
Multiple deficiencies were identified in the management of oxygen therapy, including a resident receiving oxygen at a higher rate than ordered, unclean oxygen concentrator filters, missing oxygen signage for three residents, failure to change oxygen tubing as ordered for two residents, and a resident receiving continuous oxygen without a physician's order or care plan intervention. Staff interviews revealed lack of awareness of facility policies and missed responsibilities in respiratory care.
Residents repeatedly reported dissatisfaction with being served the same food items, such as potatoes and green beans, multiple times a week. Despite these grievances being documented and communicated to the Dietary Manager and Administrator, no immediate changes were made to the menu, and the issue persisted for several months.
A resident with hypertension and cognitive impairment had a DNR form that was signed by an NP but lacked a date, resulting in an incomplete document. Staff interviews revealed that the admissions nurse is responsible for preparing the DNR form, which should then be signed and dated by the NP and checked during the 24-hour chart review. The missing date was identified during a review, and it was noted that the NP was new to the process.
A nurse failed to ensure a resident with moderate cognitive impairment swallowed prescribed medications, leaving a cup with nine pills on the overbed table and documenting administration without observation. The nurse left the medications unattended due to an urgent need to use the bathroom, contrary to facility policy requiring staff to watch residents take their medications.
A resident receiving enteral feedings via gastrostomy tube had a plastic syringe stored with the plunger engaged and liquid residue remaining inside, rather than being separated, rinsed, and allowed to air dry. Nursing staff were unaware of the correct procedure for cleaning and storing the syringe, and this improper practice was observed and confirmed through staff interviews.
Two residents who were assessed as safe and cognitively intact smokers were not allowed to smoke independently according to their preference, but were instead required to follow a strict, staff-supervised smoking schedule. Both residents expressed frustration and anxiety over these restrictions, and staff confirmed their repeated requests to smoke outside of scheduled times. Facility leadership stated the policy was implemented for safety, but could not explain why independently safe smokers were not permitted to smoke freely.
A resident with atrial fibrillation on warfarin therapy did not receive a scheduled INR lab as ordered, and the NP was not notified of the missed test. Documentation confirmed the INR was not checked, and interviews with nursing staff and leadership revealed a lack of awareness and communication regarding the missed lab, resulting in a deficiency related to failure to notify the provider of significant changes or omissions in care.
A resident with severe cognitive impairment and a history of wandering and aggressive behaviors was not provided with consistent supervision, particularly during overnight hours when a 1:1 sitter was not assigned. This lapse allowed the resident to enter another resident's room, take personal belongings, and make physical contact, resulting in minor injury. Staff interviews confirmed that supervision was not maintained at all times, leading to the incident.
A resident with atrial fibrillation on warfarin therapy did not receive an ordered INR test after the medication was held due to elevated levels. Although the warfarin was not administered as directed, there was no documentation or lab result for the required INR test, and staff interviews confirmed the test was missed.
A facility failed to update a care plan for a resident who no longer had an indwelling urinary catheter. Despite the catheter's removal and a subsequent MDS assessment indicating frequent urinary incontinence, the care plan still included the catheter. The MDS nurse confirmed the oversight, and the Administrator expected the care plan to accurately reflect the resident's condition.
A facility failed to maintain accurate medical records for a resident's medication management. The resident had orders for Atorvastatin, Insulin Lispro, and water flushes, which were not documented as administered or refused on the MAR. A nurse confirmed she provided the medications but forgot to sign off. The administrator expects complete and accurate records.
A resident in a long-term care facility was affected by the misappropriation of Hydrocodone tablets, which were not administered as needed and went missing from the medication cart. Despite receiving scheduled Oxycodone, the Hydrocodone was last accounted for during a narcotic count but was missing during the next shift change. Four nurses had access to the medication cart, but none admitted to taking the medication, and all tested negative for opiates. The facility's investigation could not determine the responsible party, and the local police and DEA were notified.
A resident, who required a two-person assist for bed mobility, fell from the bed while receiving care from a Hospice Aide who did not follow the care plan. The aide attempted to provide care alone, resulting in the resident falling and sustaining a skin tear. The incident revealed a failure in communication and adherence to care protocols.
Failure to Report Suspected Drug Use to Law Enforcement
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime to law enforcement after a resident was identified with an odor of marijuana upon returning from the smoking area. Staff immediately reported the odor to the assigned nurse, who then conducted a drug screen with the resident's consent. The drug screen tested positive for cannabinoids (THC), and the resident later admitted to having smoked a THC vape obtained from another resident. A search of the resident's room was conducted, but no illegal substances were found. Despite the facility's policy requiring law enforcement to be contacted when items posing a health and safety risk are found or suspected, the Director of Nursing and the Administrator decided not to notify law enforcement. Their rationale was based on the absence of physical evidence after the room search and the belief that law enforcement would not be able to take further action. The failure to report the incident to law enforcement constituted a deficiency in following the facility's own policy and regulatory requirements.
Failure to Assess and Supervise Smoking Resident per Policy
Penalty
Summary
The facility failed to complete a smoking assessment upon admission for a resident who was identified as a smoker and did not provide supervision or retain smoking materials in accordance with its smoking policy. The resident's care plan, initiated at admission, indicated a preference for smoking and required supervision, but there was no evidence of a completed smoking assessment until several months later. Staff interviews revealed confusion and lack of awareness regarding the resident's smoking status and supervision needs, with some staff believing the resident was independent and others unaware of the care plan requirements. The resident reported smoking independently since admission and keeping smoking materials in his possession, contrary to the facility's policy for supervised smokers. Observations confirmed that the resident was never supervised while smoking and had unrestricted access to cigarettes and a lighter. Staff members, including nurse aides and nurses, stated they were not informed or educated about the resident's need for supervision and did not recall the resident being listed as a supervised smoker. Unit management and the administrator were also unaware of the lack of an initial smoking assessment and the discrepancy between the care plan and actual practice. Communication breakdowns were evident, as staff relied on posted lists and verbal updates, which did not accurately reflect the resident's assessed needs. The facility's failure to assess, supervise, and control access to smoking materials for a resident requiring supervision constituted a deficiency in accident prevention and adherence to policy.
Incorrect Morphine Dose Administered Due to Order Clarity and Measurement Error
Penalty
Summary
A nurse failed to accurately measure and administer a liquid narcotic medication, resulting in a resident receiving a significantly higher dose of morphine than prescribed. The physician's order specified morphine sulfate concentrate at a strength of 20 mg/mL, with instructions to give 5 mg by mouth every two hours as needed. However, the order did not specify the corresponding milliliter amount for the 5 mg dose, requiring the nurse to calculate the correct volume. On the night in question, the nurse signed out and administered 1 mL (20 mg) of morphine instead of the prescribed 0.25 mL (5 mg), as documented on the controlled substance receipt sheet and the Medication Administration Record (MAR). The error was identified by the nurse shortly after administration, and she reported the incident to the provider. The resident, who had a complex medical history including metastatic lung cancer, heart failure, COPD, anxiety disorder, and other conditions, was being managed with comfort measures and was not morphine-naive. The nurse and nurse aide closely monitored the resident's vital signs and oxygen saturation following the administration of the incorrect dose. The resident initially remained alert and stable, but later became less responsive, prompting further assessment and intervention by the nurse practitioner, including administration of Narcan to reverse the effects of the morphine. Interviews with facility staff, including the DON, nurse manager, nurse practitioner, pharmacist, and medical director, confirmed that the error was due to the lack of clarity in the original physician order, which did not specify the volume to be administered. The error was not attributed to a lack of knowledge or intent, but rather to the need for calculation based on the medication concentration. The incident was recognized as a failure to follow professional standards of medication administration, specifically in ensuring accurate measurement and documentation of narcotic medications.
Failure to Document Medication Orders and Administration in Resident Record
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical record was complete regarding medication orders and documentation of medication administration. A resident with metastatic lung cancer was admitted and, during an episode of non-responsiveness, a Nurse Practitioner (NP) gave verbal orders for two doses of Narcan and one dose of Lasix. These medications were administered by nursing staff, as confirmed by sign-out records from the emergency medication supply. However, the orders were never entered into the resident's electronic medical record, and the administration of these medications was not documented on the Medication Administration Record (MAR). Multiple nurses were present when the NP gave the orders, but the NP did not specify which nurse was responsible for entering the orders. One nurse attempted to enter the order for Narcan but was unable to find the correct form in the electronic system, resulting in the order not being entered and the administration not being documented. Interviews with staff confirmed that the medications were administered per the NP's verbal orders, but no documentation was made in the resident's record or MAR, as required by facility policy and professional standards.
Failure to Protect Resident from Exploitation by Staff
Penalty
Summary
A nurse aide (NA) at the facility engaged in conduct that failed to protect a resident's right to be free from exploitation. The NA discussed her personal housing difficulties with a resident who was moderately cognitively impaired, suffering from depression, anxiety, and a cognitive communication disorder. The NA asked the resident if she could live in his personal home while he was at the facility, and the resident, described as goodhearted and trusting, considered allowing the NA and her friend to house-sit. The resident provided information about where the house key was located, and the NA attempted to access the home by searching for the key and then requesting it from the resident's neighbor. The neighbor refused to provide the key and notified the resident's family member, who was the financial proxy and health power of attorney. The family member and neighbor reported the incident to facility administration. Interviews with the resident, the NA, the neighbor, and the family member revealed that the resident initially agreed to allow the NA to stay at his home but changed his mind after learning more about the NA's personal situation. The NA claimed her intent was to assess the home for providing private care after the resident's discharge, but she admitted to going to the house and seeking the key from the neighbor. The neighbor and family member both stated that the NA expressed a desire to stay in the resident's home, and the family member emphasized the resident's vulnerability due to his cognitive and emotional state, as well as his use of pain medications. The NA was suspended and subsequently terminated for attendance issues, but the facility's initial investigation did not substantiate the allegation of exploitation, focusing instead on the lack of harm and the fact that the NA did not gain access to the home or property. Despite the lack of physical harm or property loss, the facility failed to recognize and substantiate the exploitation that occurred when the NA attempted to benefit from her relationship with a vulnerable resident by seeking access to his personal home. The former administrator later acknowledged that the situation should have been substantiated as exploitation, given the NA's actions and the resident's inability to fully understand the ramifications. The facility did not complete a plan of correction for misappropriation of property or exploitation related to this incident.
Failure to Report Alleged Exploitation to APS
Penalty
Summary
The facility failed to report an allegation of misappropriation of property and exploitation to Adult Protective Services (APS) as required by its own policy. The policy stated that the Administrator must immediately notify APS of any incident involving abuse, mistreatment, neglect, or misappropriation of personal property. In this case, a resident was allegedly exploited by a nursing assistant (NA), who attempted to gain access to the resident's personal home by convincing the resident to allow her to stay there and by seeking a key from the resident's neighbor. The neighbor and a family member, who was the resident's financial proxy and health power of attorney, reported that the resident was easily manipulated and that the NA attempted to exploit the resident to become a squatter in the resident's home. The facility became aware of the incident and suspended the NA pending investigation, and notified local law enforcement, but there was no documentation that APS was notified at any point. Interviews with facility staff revealed a lack of communication and clarity regarding the responsibility for reporting such incidents to APS. The former Administrator could not recall if APS was notified and stated that the Social Worker was usually responsible for such notifications, but the Social Worker reported she was not informed of the incident and therefore did not notify APS. The investigation report and other documentation confirmed that APS was not notified of the allegation, and facility leadership acknowledged that no plan of correction was completed for this reporting failure.
Deficiencies in Oxygen Therapy Management and Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents, as evidenced by multiple deficiencies in oxygen therapy management. One resident with respiratory failure, pneumonia, and stroke was observed receiving oxygen at a rate higher than the physician's order, with the oxygen concentrator's air intake filter covered in dust. Staff interviews revealed a lack of knowledge regarding the cleaning schedule and manufacturer's instructions for the concentrator, and the resident's oxygen order was not followed until after the discrepancy was identified. The facility's policy required cleaning according to manufacturer guidelines, but this was not consistently implemented. Three residents receiving continuous oxygen therapy did not have required oxygen signage posted near their rooms, despite being observed with oxygen concentrators in use. Staff, including the unit manager and DON, were unaware that signage was missing and did not know it was required by facility policy. Additionally, two residents had not had their oxygen tubing changed as ordered, with tubing observed to be dirty and dated two weeks prior. Staff interviews indicated that tubing changes were missed due to lack of supplies and competing priorities during shifts, and management was not aware of the missed changes. Another resident was found to be on continuous oxygen without a physician's order or care plan intervention for oxygen use. The resident had been on oxygen for at least a week, and both the unit manager and nurse practitioner assumed an order was in place or that it had been missed. The DON confirmed that nursing staff should have ensured an order was entered when the resident began oxygen therapy, but this was not done. These findings demonstrate failures in following physician orders, maintaining equipment, ensuring proper documentation, and adhering to facility policies for respiratory care.
Failure to Address Resident Grievances Regarding Repetitive Menu Items
Penalty
Summary
The facility failed to resolve grievances reported by residents during Resident Council meetings over a period of four out of six months. Residents repeatedly complained that they were being served the same food items, specifically potatoes and green beans, multiple times a week for both lunch and dinner. These concerns were documented in the Resident Council Minutes and were consistently brought to the attention of facility staff, including the Dietary Manager and the Administrator. Despite these ongoing complaints, the menu remained unchanged, with the Dietary Manager indicating that the menu was provided by the corporate office and could not be altered. Residents expressed ongoing dissatisfaction, stating that their concerns about repetitive meals were not addressed and the issue persisted over several months. Staff interviews confirmed that the complaints were a consistent problem and that the Administrator was aware of the grievances. However, the facility did not implement any immediate changes to the menu, and the same food items continued to be served as per the existing schedule.
Incomplete DNR Form Due to Missing Date
Penalty
Summary
The facility failed to fully complete a Do Not Resuscitate (DNR) form for a resident with diagnoses including hypertension and cognitive impairment. Upon review, the resident's DNR form was found to be signed by the Nurse Practitioner (NP) but was missing the required date. The electronic medical record did contain a physician's order for DNR with a date, but the paper DNR form itself was incomplete. Interviews with staff revealed that the process for completing DNR forms involves the admissions nurse filling out the form, which is then to be signed and dated by the NP before being scanned into the electronic record and stored in a binder at the nurse's station. Both the Unit Manager and DON confirmed that the DNR form should be dated and checked during the 24-hour chart review after admission. The NP stated that forms are typically dated before she signs them, but in this instance, the date was missing. The Administrator acknowledged that the NP was responsible for both signing and dating the form and noted that the NP was new to the process.
Medications Left Unattended; Nurse Failed to Ensure Ingestion
Penalty
Summary
A deficiency occurred when a nurse failed to ensure a resident swallowed their prescribed medications during medication administration. The resident, who was moderately cognitively impaired and had diagnoses including diabetes and congestive heart failure, was observed with a medication cup containing nine pills left on her overbed table. The resident was unable to identify the medications or the reason they were present. The nurse responsible for administering the medications reported that she had an urgent need to use the bathroom and left the medications with the resident, without confirming ingestion. The nurse had documented the medications as administered in the medication administration record, despite not witnessing the resident take them. Interviews with facility leadership confirmed that the nurse did not follow expected procedures, which require staff to observe residents swallowing their medications and prohibit leaving medications at the bedside. The nurse acknowledged that the resident may have spit out the pills after initially putting them in her mouth. Both the DON and the Administrator stated that the nurse's actions did not align with facility policy or professional standards for medication administration.
Improper Storage and Handling of Enteral Feeding Syringe
Penalty
Summary
A deficiency was identified regarding the storage and handling of an enteral feeding syringe for a resident with a gastrostomy tube. The resident, who had a history of stroke and difficulty swallowing, was receiving enteral feedings and medications through the tube as ordered by her physician. Observations revealed that the plastic syringe used for administering feedings and medications was stored with the plunger engaged in the barrel and contained a cream-colored liquid residue. The syringe was kept in a plastic bag hanging from the feeding pump pole, and this condition persisted for several hours after use. Interviews with nursing staff indicated a lack of awareness regarding the proper procedure for cleaning and storing the syringe. Both the nurse in training and the supervising nurse were unaware that the plunger should be separated from the barrel, and the syringe should be rinsed and allowed to air dry before storage. The nurse practitioner confirmed that the enteral feeding product contained sugar, which could promote bacterial growth if left in the syringe. The improper storage and cleaning practices were directly observed and confirmed through staff interviews.
Failure to Honor Resident Choice for Independent Smoking
Penalty
Summary
The facility failed to honor the rights of residents who were assessed as safe smokers to smoke independently according to their personal preference. Despite both residents being evaluated as cognitively intact and safe to smoke unsupervised, the facility required them to adhere to a strict smoking schedule and only allowed smoking at designated times under staff supervision. The facility's policy and smoking assessment documentation indicated that residents deemed safe could smoke independently, but in practice, all residents were restricted to the same supervised schedule. This restriction was not based on individual assessments but rather a facility-wide policy change. Two residents expressed frustration and anxiety due to their inability to smoke when they wished, with one resident reporting increased anxiety and another expressing upset and frustration at having to wait for staff and scheduled times. Staff interviews confirmed that these residents frequently requested to smoke outside of the scheduled times and became upset or anxious when unable to do so. Facility leadership acknowledged the policy was implemented for safety reasons after previous incidents of residents smoking in unsafe areas, but could not provide a reason for restricting independently assessed safe smokers to the supervised schedule.
Failure to Notify NP of Missed INR Lab for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to notify the Nurse Practitioner (NP) when a resident's ordered International Normalized Ratio (INR) test was not completed as scheduled. The resident, who had a history of atrial fibrillation and was prescribed warfarin, had an elevated INR of 4.0, prompting the NP to order the medication to be held and the INR to be rechecked on a specific date. Documentation showed that the warfarin was not administered during the specified period, but there was no record of the INR test being completed or its results for the ordered date. Nurse #1, who was assigned to the resident on the day the INR was to be checked, could not recall performing the test and confirmed that if the result was not documented, the test was not done. Interviews with the NP, DON, and Administrator confirmed that the INR was not checked as ordered and that the NP was not notified of the missed lab. The NP stated that she expected to be informed if the lab was not completed, especially given the resident's fluctuating INR levels and the need for close monitoring. The DON and Administrator also indicated that they were unaware the lab had been missed and agreed that the NP should have been notified. The lack of notification and failure to follow through with the ordered lab test constituted the deficiency.
Failure to Provide Adequate Supervision for Resident with Wandering Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent a resident with known wandering and behavioral issues from entering another resident's room and attempting to take personal belongings during the night. The resident in question had a history of severe cognitive impairment, agitation, hallucinations, delusions, and physical behaviors that impacted her care and interactions. Despite documented behaviors such as wandering, aggression, and poor safety awareness, supervision was not consistently maintained, particularly during the overnight shift when a 1:1 sitter was not assigned. The resident's care plan and medical records indicated ongoing behavioral challenges, including restlessness, resistance to redirection, and attempts to enter other residents' rooms. Staff notes and psychiatric assessments repeatedly documented the resident's difficulty with redirection and her tendency to wander and interact inappropriately with others. On the night of the incident, staff responsible for supervising the resident were attending to other duties, leaving the resident unsupervised, which allowed her to enter another resident's room and take his cell phone and glasses. The incident was only discovered when the other resident called out for help. Interviews with staff confirmed that supervision was not maintained at all times, especially during the night shift, and that the resident was not assigned a dedicated 1:1 sitter during those hours. The lack of continuous supervision, despite the resident's documented behaviors and risks, directly led to the incident where she was able to access another resident's belongings and make physical contact, resulting in minor skin indentations. The facility's failure to ensure adequate supervision for a resident with known high-risk behaviors constituted the deficiency.
Failure to Complete Ordered INR Test for Resident on Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to complete an International Normalized Ratio (INR) test as ordered by the physician for a resident receiving anticoagulant therapy. The resident, who had a history of atrial fibrillation and was on warfarin, had fluctuating INR levels that required close monitoring. Physician orders specified that the resident's warfarin should be held and the INR rechecked on a specific date following an elevated INR result. Documentation review revealed that the warfarin was appropriately held, but there was no record of the required INR test being completed on the ordered date. Nursing staff could not confirm that the test was performed, and there was no lab result or documentation to indicate it was done. Interviews with facility staff, including the nurse assigned to the resident, the Nurse Practitioner, the DON, and the Administrator, confirmed that the INR test was missed and not documented as completed. The care plan for the resident included completing labs as ordered and reporting abnormal results, but the lack of follow-through on the physician's order for INR testing constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs and was properly monitored.
Failure to Update Care Plan for Urinary Catheter Removal
Penalty
Summary
The facility failed to revise the care plan for a resident who no longer had an indwelling urinary catheter. The resident was admitted with a neuromuscular disorder of the bladder and initially had a care plan for an indwelling urinary catheter due to neurogenic bladder. A nursing progress note indicated that the catheter was removed, and a subsequent Minimum Data Set (MDS) assessment showed the resident had frequent urinary incontinence and was not coded as having an indwelling urinary catheter. However, the active care plan, last reviewed on December 3, 2024, still included the catheter. During an interview, the MDS nurse confirmed the oversight, acknowledging that the care plan should have been updated to reflect the resident's current status. The Administrator expressed that the care plan should accurately represent the resident's condition.
Failure to Maintain Accurate Medication Records
Penalty
Summary
The facility failed to maintain accurate medical records for a resident in the area of medication management. The deficiency involved a resident who was admitted to the facility and had physician orders for Atorvastatin, Insulin Lispro, and water flushes via G-tube. On January 18, 2025, the Medication Administration Record (MAR) did not indicate that these medications and treatments were provided or refused at 6:00 PM. Nurse #1, who was responsible for the resident's care during that time, confirmed in a phone interview that she administered the medications and water flush but forgot to document it in the MAR. The facility administrator stated that medical records are expected to be complete and accurate.
Misappropriation of Controlled Medications in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medications. The incident involved a resident who was admitted with a diagnosis of arthritis and had orders for Oxycodone and Hydrocodone for pain management. Despite the resident receiving scheduled Oxycodone, the Hydrocodone tablets, which were prescribed as needed, were not administered and were found to be missing from the medication cart. An investigation revealed that 26 Hydrocodone tablets were dispensed from the pharmacy but were never documented as administered. The tablets were last accounted for during a narcotic count between two nurses, but were missing during the next shift change. Four nurses had access to the medication cart, but none admitted to taking the medication, and all tested negative for opiates. The facility's investigation could not determine which nurse was responsible for the missing medication. The facility's policy on abuse, neglect, and exploitation includes the protection of resident property, and the misappropriation of the Hydrocodone tablets violated this policy. The investigation involved reviewing the actions of the nurses who had access to the medication cart, but the missing medication was never found. The local police and Drug Enforcement Administration were notified, and the facility submitted a report of loss or theft of controlled substances.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to provide adequate supervision and care for a resident, leading to an accident. Resident #5, who was moderately cognitively impaired and required extensive assistance from two staff members for bed mobility, was left in the care of a Hospice Aide who did not follow the care plan. The care plan specified that Resident #5 needed a two-person assist for bed mobility and transfers, but the Hospice Aide attempted to provide care alone, resulting in the resident falling from the bed. During the incident, the Hospice Aide was giving Resident #5 a bed bath without the assistance of another staff member, contrary to the care plan requirements. The resident rolled off the bed and fell approximately three and a half feet, landing on her right side. This fall resulted in a skin tear on the resident's face. The Hospice Aide admitted to not using a second person for assistance, despite knowing that the resident typically required it. Interviews with staff revealed that the Hospice Aide did not check in with the facility's nursing staff to verify the care plan requirements. The Unit Manager confirmed that hospice staff had been educated on the resident's needs but was unsure why the Hospice Aide did not seek assistance. The incident highlighted a breakdown in communication and adherence to established care protocols, leading to the resident's fall.
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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