GRANTS PASS, OR - State health inspectors documented multiple care deficiencies at Highland House Nursing & Rehabilitation Center during a June 2024 inspection, including failures to conduct required care conferences for new admissions, improper administration of cardiac medications, and lack of post-fall monitoring protocols.
Care Planning Requirements Not Met for New Admissions
Inspectors found the facility failed to conduct required care plan conferences within appropriate timeframes for multiple newly admitted residents. Federal regulations mandate that nursing homes hold care conferences within specific periods to ensure residents and their representatives can participate in developing individualized care plans.
Four residents admitted between February and May 2024 experienced significant delays or complete absence of required care planning meetings. Resident 21, admitted with a cervical vertebra fracture, had only one care conference on the day following admission but no subsequent meetings despite remaining at the facility for over two months. When interviewed, the resident could not recall participating in any care conferences since admission.
The medical record showed a comprehensive assessment was completed on April 10, 2024, but the required follow-up care conference within seven days of that assessment never occurred. This represents a critical gap in the care planning process, as these meetings serve as the primary mechanism for residents and families to communicate their preferences, goals, and concerns to the care team.
Resident 49, admitted in April 2024 with a rib fracture, experienced similar lapses. The resident's family representative reported being unaware of any care conferences since admission, and facility records confirmed no meetings had been documented. The comprehensive assessment was completed on May 21, 2024, but again, no timely care conference followed.
Another concerning case involved Resident 25, a long-term resident with stroke-related impairments and moderately impaired cognition. The resident's representative stated that quarterly care conferences, which had previously been routine, seemed to have stopped occurring. Records showed a six-month gap between care conferences from January through June 2024.
When interviewed, the Social Service Director acknowledged contacting the representative only one day before scheduled meetings and made no subsequent attempts to reschedule when representatives were unable to attend. This practice effectively excluded family members from meaningful participation in care planning decisions.
Cardiac Medication Administered Outside Physician Parameters
The inspection revealed potentially dangerous medication administration practices involving Resident 16, who was prescribed metoprolol tartrate for heart health. This beta-blocker medication requires careful monitoring because it lowers both blood pressure and heart rate, and administering it when vital signs are already low can cause serious complications.
The physician's order specifically instructed staff to hold the medication if the resident's blood pressure fell below 100/60 or heart rate dropped below 60 beats per minute. These parameters exist because administering the medication under these conditions could cause dangerously low blood pressure (hypotension) or slow heart rate (bradycardia), potentially leading to dizziness, fainting, falls, or inadequate blood flow to vital organs.
Despite these clear instructions, medication administration records from May and June 2024 showed Resident 16 received metoprolol on at least 28 occasions when blood pressure readings were below the specified threshold. On multiple dates, the resident's systolic blood pressure measured between 98 and 116, with diastolic readings as low as 47—well below the hold parameters.
Additionally, staff administered the medication on two evening shifts when the resident's heart rate measured 59 beats per minute, one beat below the hold parameter. Even more concerning, vital signs were not documented as obtained on 21 shifts during the two-month period, meaning staff may have administered the medication without checking whether it was safe to do so.
Medical protocols for cardiac medications exist specifically to prevent adverse events. When blood pressure or heart rate falls too low, patients can experience inadequate perfusion to the brain and other organs. In elderly residents, this increases fall risk substantially, as orthostatic hypotension (sudden drops in blood pressure when standing) becomes more likely. Falls in this population often result in serious injuries including hip fractures, head trauma, and hospitalizations.
The facility's medication management system also failed Resident 16 in another way. The resident had a prescription for furosemide, a diuretic to be given as needed for fluid retention when weight gain exceeded two pounds. However, staff obtained weights only 12 times during the 31-day month of May 2024. Records showed the resident's weight increased from 152 to 154 pounds over one two-day period, and from 150 to 155 pounds over a four-day period later in the month—weight gains that should have triggered the as-needed medication but went unaddressed.
Failure to Monitor Resident After Documented Fall
On March 14, 2024, Resident 51 experienced an unwitnessed fall, slipping out of bed. The facility's own fall investigation documentation indicated that neurological assessments should be initiated—a standard protocol because falls, particularly those involving the head, can result in traumatic brain injuries that may not be immediately apparent.
Elderly individuals taking blood thinners or with underlying conditions are at particular risk for delayed bleeding in the brain following head trauma. Subdural hematomas can develop slowly over hours or days, and symptoms may be subtle initially. Standard post-fall protocols typically require neurological checks at regular intervals for at least 72 hours, monitoring for changes in consciousness, pupil response, balance, coordination, speech, and other neurological functions.
Despite documentation indicating neurological monitoring should occur, inspectors found no evidence that staff conducted these critical assessments. Progress notes from the days following the fall made brief mentions of the resident reporting wrist and back pain, and later notes indicated the resident was walking without pain. However, no systematic neurological evaluations were documented.
When the facility's LPN Resident Care Manager reviewed the chart during the inspection, she acknowledged that staff had not monitored the resident after the fall as required. The Director of Nursing Services stated that facility policy required monitoring residents twice daily after falls, but could not produce the neurological assessments when requested by inspectors.
This failure represents a significant patient safety concern. Without proper post-fall monitoring, staff cannot detect complications early enough to seek emergency medical intervention. Changes in neurological status following a fall can indicate life-threatening conditions requiring immediate hospitalization.
Questions About Mental Health Diagnosis Documentation
Inspectors also identified concerns about the documentation supporting a schizophrenia diagnosis for Resident 16. The resident was prescribed aripiprazole, an antipsychotic medication used to treat both depression and schizophrenia. However, review of multiple hospital records from February and October 2023 showed no schizophrenia diagnosis in the resident's past medical history. Psychiatric evaluations during these hospitalizations consistently documented normal mood, behavior, and thought content.
The diagnosis of schizophrenia was added to the facility's records on October 17, 2023, classified as an admitting diagnosis despite the resident having been admitted earlier in the year. This occurred shortly after the resident reported seeing insects in the room during a urinary tract infection—a condition well-known to cause temporary hallucinations and confusion in elderly individuals, particularly when the infection goes untreated.
Professional standards require mental health diagnoses to be based on thorough psychiatric evaluation, documented history of symptoms, and clear clinical evidence. A single episode of reported hallucinations during a medical illness does not typically warrant a schizophrenia diagnosis, especially when previous comprehensive psychiatric evaluations found no evidence of thought disorders.
Additional Issues Identified
Beyond these major concerns, the inspection documented other care delivery problems. Resident 33, who had a physician order for a laxative medication twice daily for bowel regulation, did not receive the prescribed medication 32 times over a 41-day period. Staff reported the resident refused the medication but acknowledged they had not consistently notified the physician about the refusals as required. Repeated refusal of prescribed medications should prompt care team discussion about alternatives or underlying reasons for refusal.
The inspection findings at Highland House reflect systemic issues in care planning participation, medication safety protocols, post-fall monitoring, and clinical documentation. When care conferences do not occur as required, residents and families lose their voice in treatment decisions. When medications are administered outside physician parameters or vital signs are not checked before administration, residents face preventable risks. When falls are not properly monitored, life-threatening complications can go undetected.
Federal regulations exist to ensure nursing home residents receive individualized care based on comprehensive assessment and planning, with active participation from residents and their representatives. These requirements recognize that quality care depends on accurate assessment, appropriate care planning, proper implementation of physician orders, and systematic monitoring for complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland House from 2024-06-14 including all violations, facility responses, and corrective action plans.
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