LAURINBURG – A Scotland County nursing home has been cited for 16 infractions following an investigation by the state.
The Department of Health and Human Services Division of Health Service Regulation found Willow Place Assisted Living and Memory Care to be in violation of several serious state codes concerning patient care and staffing between April and May.
Some of the gravest infractions include failure to comply with doctor’s orders regarding patient care, improperly administering medication, lack of adequate nutrition, and in one case failure to protect a resident from another violent, combative patient with Alzheimer’s.
The review was prompted by complaints from patients and family members.
The DHHS gave the Stonewall Road facility until June 24 to correct some violations and until July 9 for others and in the meantime has temporarily suspended the center’s ability to admit new residents. The state also issued an intent to downgrade Willow Place’s license to a conditional status.
Willow Place will be given the opportunity to submit a written statement and documentation to the state to prove that they are in compliance. If they fail to do so, they will be downgraded to provisional status.
Willow Place officials could not be reached for comment.
The two-part investigation took place from May 17 to 19 and May 22 to 25 and consisted of record checks, observation of care and interviews with staff, residents and family members.
One of the report’s finding was failure of staff to comply with doctor’s medical instructions.
According to the report, one patient was required to wear compression stockings for a deep vein thrombosis blood clot. The patient told inspectors that staff had only put the stockings on once in a two-week span, despite documenting the stockings were applied as ordered by the doctor.
“He wanted to wear the stockings every day, but the staff found them difficult to apply and did not put the stockings on him most days,” the report said. “There was documentation on the Medication Administration Records that the stockings were being applied.”
Sampling of patients and interviews with staff found that doctors were not notified of lasting elevated blood sugar levels in the case of a diabetic patient even when the patient’s Accu check test showed a blood sugar level of over 400 on five occasions and over 500 on six occasions.
The report also cites failure to order necessary labs and blood work to maintain a patient’s care, and failing to notify a primary care physician that a patient refused to wear a medically necessary oxygen device.
The investigation also found that patients’ nutritional needs were in jeopardy from an inadequately supplied kitchen, poorly planned meals, therapeutic menus with dietary restrictions that were not followed, and that the kitchen had been without a dietary manager since April 12.
An inspector’s interview with staff showed that although a food delivery was made every Tuesday the food ran out before the next delivery.
“We run out of things like bread, eggs and milk, but we tell the administrator and they will go to the store and get what we need,” said an unidentified employee.
The review also found that patients were not given adequate servings of food. One inspector observed that a serving of eggs “approximately the size of a tablespoon” was placed on residents’ trays, and other trays were sent out with portions of food missing.
Investigators also found that medications were not administered properly for seven of the 10 sampled residents.
One resident was discharged from the hospital on May 14 with a urinary tract infection; on May 16 the patient’s prescription for antibiotics had still not been filled.
Another resident was not administered Valium twice a day as prescribed; a count of the patient’s medication revealed leftover pills.
Another resident was prescribed 120 Oxycodone pills, and the medication was checked into the facility on May 5. On May 25 an employee discovered that 60 of the pills were missing and reported it to Laurinburg police.
The incident is still under investigation according to Assistant Chief Cliff Sessoms.
A sampling of the facility’s time sheets showed Willow Place to be understaffed on at least six days between April and May.
“The failure of the facility to assure that there was adequate staff 26 of 36 shifts sampled resulted in the staff not being able to meet the needs of one resident [sic] who was not assisted out of her bed in time for breakfast,” the reports states. “This failure is detrimental to the health and safety of residents and constitutes a Type B violation.”
Another infraction involved an aggressive Alzheimer’s patient who was in good physical condition and fully ambulatory targeting another weaker patient repeatedly. The staff had not been given any special instructions as to how to handle the aggressive patient.
The state does not have specific rules regarding separate housing of or restraint of Alzheimer’s patients, merely general guidelines.
The licensing rules for adult care homes states, “Special care unit for persons with Alzheimer’s Disease or related disorders means an entire facility or any section, wing or hallway within an adult care home separated by closed doors from the rest of the home, or a program provided by an adult care home, that is designated or advertised especially for special care of residents with Alzheimer’s Disease or related disorders.”
The rules state only that “safety measures addressing dementia specific dangers such as wandering, ingestion, falls and aggressive behavior,” with “staffing in the unit” must be in place.
Willow Place and the state have created a plan of protection to address some of the immediate safety concerns.
The plan said that medical charts must be reviewed for aggressive behavior and correct medical staff will be alerted, and residents will be assessed before admission for aggressive patterns of behavior.
