Nc State Veterans Home-Kinston

Inspectors wroteBased on record review, and interviews with staff, Responsible Party, Manager at the facility's contracted x-ray company, and Physician the facility failed to ensure nursing staff reported a fall with injury to a physician/medical provider resulting in the physician/medical provider not having all relevant information as a treatment plan was developed and implemented. On [DATE] Resident # 1 sustained a fall while Nurse Aide # 1 and Nurse Aide # 2 were caring for him. The resident was crying in pain while on the floor and had obvious injury to his left knee. The on-call provider was erroneously informed that the resident had pain, warmth, and swelling to the left knee for no known reason. The provider's treatment plan included a STAT (right away) x-ray of the left knee but no orders for stabilization of the resident's leg. [...]

Inspectors wroteBased on record review, observations, and interviews with staff, Responsible Party, a Manager at the facility's contracted x-ray company, and Physician the facility failed to protect a severely cognitively impaired resident's right to be free of neglect after he sustained a fall with obvious injury on [DATE] between 6:00 AM and 7:00 AM. Nurse Aide # 1 and Nurse Aide # 2 were preparing to use a sit-to stand lift to transfer Resident # 1, who was totally dependent on staff for sitting balance and required a total mechanical lift for transfers, from the bed to the chair when the resident slid off the side of the bed and landed on his knees. The resident was crying while on the floor and Nurse Aide # 1 reported she could tell something was wrong. Resident # 1 was lifted to the bed without a nursing assessment. [...]

Inspectors wroteBased on record review, and interviews with staff, the facility's contracted x-ray company, Responsible Party, and Physician the facility failed to ensure nursing staff effectively communicated amongst themselves to ensure staff who cared for Resident #1 were aware of a fall with obvious injury that occurred and that Resident # 1 received comprehensive assessment and treatment. Resident # 1, who was severely cognitively impaired, sustained a fall on [DATE] between 6:00 AM and 7:00 AM. Night shift nursing staff members, who were assisting with Resident # 1 during the accident, were aware the resident was crying in pain as a result of the fall but did not disclose the fall. A comprehensive assessment was not completed prior to moving the resident after the fall. [...]

Inspectors wroteBased on observation, record review and interviews with staff, and physician the facility failed to provide the necessary supervision to prevent accidents and provide care in a safe manner for a severely cognitively impaired resident totally dependent on staff for care and required a total mechanical lift for transfers. On [DATE] between 6:00 AM and 7:00 AM Nurse Aide #1 and Nurse Aide #2 were preparing to use a sit-to stand mechanical lift to transfer Resident # 1 from the bed to the chair. On [DATE] while seated on the side of the bed, the resident slid to the floor on his knees and was crying on the floor. The resident was manually lifted from the floor to the bed following the fall. NA #1 reported Nurse #1, who was the supervising nurse for NA # 1 and NA # 2, then helped them transfer Resident # 1 from the bed to the wheelchair with the sit-to-stand lift. [...]

Inspectors wroteBased on record reviews and interviews with facility staff, physician's office staff, Nurse Practitioner (NP), and Medical Director, the facility failed to notify the physician or nurse practitioner (NP) immediately of an unwitnessed fall with head injury for a resident prescribed an anticoagulant (blood thinner) in order for the physician to determine the necessary treatment plan. The resident fell on Saturday [DATE] and the physician was not notified until Monday [DATE]. Resident #1 continued to receive his anticoagulant medication. On [DATE], Resident #1 had an acute change in condition and was sent to the hospital. Resident #1's Glasgow Coma Scale (used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients) in the hospital indicated he sustained a severe traumatic brain injury. [...]

Inspectors wroteBased on record reviews and interviews with the Responsible Party (RP), staff, Nurse Practitioner (NP), and Medical Director, the facility failed to: explain to the resident and RP the risk of life threatening consequences and the importance of hospital evaluation when a severely cognitively impaired resident who was prescribed an anticoagulant (blood thinner) had an unwitnessed fall with obvious signs of head injury and refused hospital evaluation; and to recognize the seriousness of a change in condition and immediately seek emergent medical care. On [DATE] Resident #1 had an unwitnessed fall and was assessed as having an abrasion with a small indentation on the top of his head described by Nurse #3 like when someone would press down into a soft mattress. The resident stated he ain't going to no hospital. [...]

Inspectors wrote2. Resident #20 was admitted to the facility on [DATE] with diagnoses that included paroxysmal atrial fibrillation, osteoarthritis, generalized muscle weakness, and difficulty in walking. The electronic medical record profile indicated Resident #20's code status as a Do Not Resuscitate (DNR). Review of Resident #20's physician orders dated [DATE] revealed he had an active DNR order in place. The DNR book kept at the nurse's station on Resident #20's hall/wing was reviewed. An effective, executed DNR status form was found. Review of Resident #20's revised active care plan dated [DATE] at 6:42 PM showed a focus area of do not attempt resuscitation. Further review of Resident #20's revised active care plan dated [DATE] at 6:42 PM indicated a focus area of attempt resuscitation. An interview was conducted on [DATE] at 4:16 pm with the Director of Nursing (DON). [...]

Inspectors wrote2. Resident #17 was admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack). Physician orders dated 8/17/2023 included Aspirin Delayed Release (an antiplatelet medication that causes blood cells not to clump together to form a clot) 81 milligrams(mg) daily. A review of the May 2024 Medication Administration Record recorded Resident #17 received Aspirin Delayed Release 81 mg daily from 5/01/2024 to 5/31/2024. Resident #17 continues to receive Aspirin Delayed Release 81 mg daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact and was not coded for antiplatelets. [...]

Inspectors wroteBased on observation, record review, and staff, physician, and police detective interviews, the facility failed to protect a cognitively impaired resident's right to be free from abuse when a staff member hit the resident in the face for 1 of 1 resident investigated for employee to resident abuse (Resident #4).

Inspectors wroteBased on staff interview and record review, the facility failed to report an allegation of staff to resident abuse to Adult Protective Services for 1 of 1 resident investigated for employee to resident abuse (Resident #4).