LAURINBURG – A Laurinburg nursing home has been cited for new infractions following a second state inspection.
Willow Place Assisted Living and Memory Care on Stonewall Road was again cited after the Department of Health and Human Services Division of Health Service Regulation conducted an inspection to address additional complaints between Aug. 8 to 11; Aug. 13 to 17 and again on Aug. 21.
The 190-page report spells out 18 violations some of which the home had already been cited for in the spring.
Willow Place submitted a Plan of Protection on Aug. 29 that said staff would receive more training to address the issues.
Cobey Culton, public information officer for NCDHS Division of Health Service Regulation would not say what, if any penalties the nursing home would face following the new round of violations.
“We can’t say what penalties would be imposed, but penalties would only be imposed after a process that includes the facility having an opportunity to informally dispute any findings,” Culton said.
A representative of Willow Place declined to comment on the new investigation.
Willow Place was first cited for 16 violations following an investigation in May. The facility was given until June 24 to correct some violations and until July 9 to address others. When administrators failed to do so, the state issued a provisional license giving operators until Oct. 11 to come into compliance or face other measures. The home was also stripped of the ability to admit new patients.
In August, Georgette Jones owner of Z&V Adult Care, which manages the facility, announced that it would close the memory care unit claiming that Z&V could better address the infractions if it did not have to deal with Alzheimer’s and dementia patients. The announcement was made in a two-paragraph letter hand delivered to the families of patients. It gave families 30-days to make other arrangements for their loved ones.
One of the new infractions dealt with the way Willow Place discharged two patients.
State guidelines say that a resident can only be discharged if one of the following criteria are met: the resident’s needs cannot be met in the facility as documented by a primary care provider, the resident’s health has improved, the safety or health of other individuals in the facility is threatened, or not paying an outstanding balance.
“This Rule is not met as evidenced by: based on interviews and record reviews, the facility failed to ensure 1 of 2 residents (#4) was being discharged for reasons related to not being able to meet the resident’s needs, and not using discharge as a means of retaliation,” the final report stated.
Patient number four is the mother of Deborah Dial who has been one of the most outspoken complainants about the issues the home is facing and its apparent unwillingness to address the problems.
Dial is pleased that her complaints have been investigated and that wrong doing was proven, but doesn’t feel it will make any difference.
“I’m relieved that it’s out in the open. Maybe things will change, but it’s doubtful,” Dial said. “It’s been a battle and a struggle to get to this point that the state will see it for themselves.”
Dial cares for her mother at home following the discharge.
The release notice Dial received in July said that the facility could no longer meet her mother’s needs, and that her physician had signed off in the request.
The investigation found that was not the case.
The investigator conducted a phone interview with the patient’s doctor who said that, “He was not able to determine whether Resident #4’s needs had changed because he had not seen the resident since June 2017. He would have to see Resident #4 to determine if her care needs had changed.”
An unidentified staff member told the state inspector that Dial’s mother was discharged because administration “just wanted to get rid of [Dial]” because she always pointed out problems with her mother’s care “and the management did not like that.”
The review found the home to be non-compliant with state regulations for staffing, an issue for which it had been cited for in May. The state sampled records for 10 days between June 5 and July 28 and found that “the facility failed to assure staffing met minimal requirements according to the census, for 36 of 45 shifts sampled.”
A former employee told the inspectors “The weekends were always short staffed. There was usually one Personal Care Aide on the Special Care Unit … one PCA on the Assisted Living side and two Medication Aides for second shift.”
The report also stated that “confidential interviews with staff revealed, the third shift [assisted living] staff spent a lot of time in the staff lounge where the television was, and oftentimes would be outside in the front of the building smoking. There were times when residents would go to the door of the [special care unit] and knock on the door to request medical attention, when the MA could not be found. Residents always knocked on the door of the [special care unit] looking for staff in the [assisted living unit.]”
Administration also failed to provide enough staff to meet personal care needs for three residents in the Special Care Unit who required help with “personal care assistance such as incontinence care, toileting, bathing and feeding … resulting in meals being given cold and delays in providing care for up to a census of 14 residents.”
Willow Place also did not provide adequate supervision to four aggressive patients who were prone to wander and would become agitated, according to the report. The lack of supervision resulted in a head injury for one resident. The home exhibited the same problem in May.
The facility was again cited for failure to coordinate care with residents’ primary care providers in the case of six residents. Some of the patients were in need of emergency care. The lack of attention “result[ed] in cardiac arrest and an anoxic brain injury for Resident #5; blood sugar results as low as 32 for Resident #2; urine leakage for a week related to a malfunctioning catheter for Resident #17; hospitalization for a seizure for Resident #3; and weight loss and behavior changes related to difficulty eating for Resident #4,” according to the report.
Findings also indicated that medications were not properly administered to five residents. Improper medication caused one patient to have seizures and another to experience increased, unnecessary pain. Three patients were not given insulin at the proper time to control blood sugar levels.
One of those patient’s was Dial’s mother who lost 13 pounds due to inadequate care, according to documents.
There were also issues with proper documentation and signatures on the medication administration records.
A problem that Dial said is ongoing. When her mother was discharged in September, Dial received another patient’s blood pressure medication.
“They put her medication in a bag with no instructions or anything. They sent Mr. [J’s] high blood medicine home with me,” Dial said. “I didn’t know what it was. I had to look it up, and then I saw his name on the pack with [the administrator’s] signature. What if I had given that to Mama? She doesn’t have problems with blood pressure. I could have killed her.”
Willow Place also continued to exhibit an inability to provide “three nutritionally adequate, palatable meals per day” and did not offer three snacks a day, the report said.
The home also did not follow doctor’s instructions for therapeutic diets for some residents, another infraction seen in the May investigation.
The inspection found that administration did not adequately respond to requests or complaints by family and residents.
Administrators were also accused of not refunding the remaining money in the personal care accounts of four patients in a timely manner after the patient was transferred to a new facility. In one case, the refund was delayed for two and a half months.
Dial said her mother is doing better now that she is at home. He blood sugar levels and weight have stabilized now that she is receiving a proper diet and proper medication, and her dementia seems to be improved.
She is happy that her mother is better, but she still wants the owners and administration of Z&V Adult Care to be punished.
“I want somebody to pay, to be prosecuted for the things they did to those people and their families. If I did anything to hurt Mama, they would be out here to lock me up,” she said.