Federal inspectors found the facility added the schizophrenia diagnosis to Resident 16's medical record on October 17, 2023, classifying it as an "admitting diagnosis" even though she had been at the facility since 2023. Hospital evaluations from February 2023 and October 2023 both documented no diagnosis of schizophrenia, with psychiatric assessments showing normal mood, behavior and thought content.
The resident was prescribed aripiprazole, an antipsychotic medication, for the fabricated diagnosis. Staff administered the drug for months based on the false medical record.
"I could not remember when I was diagnosed with schizophrenia," the resident told inspectors on June 14. "Whoever diagnosed me stated it would not be for long."
The resident's actual diagnoses included anxiety and depression. A March 2023 admission assessment found her cognitively intact with no hallucinations, delusions or problematic behaviors during the seven-day evaluation period.
Staff documented the resident experienced "inconsolable fear and crying" while on the antipsychotic medication in May 2023. Yet the facility continued the treatment based on the unsubstantiated diagnosis.
The only documented hallucination occurred on October 25, 2023, when the resident reported seeing "black bugs flying in her room" and crawling on window blinds. Laboratory results the same day revealed she had a urinary tract infection, a condition that commonly causes hallucinations in elderly patients.
A nursing assistant who worked with the resident daily told inspectors she never observed hallucinations or delusions. "At times she would report a CNA did not assist her when they had," the aide said.
When confronted about the diagnosis, Administrator Staff 1 claimed the resident's previous caregiver stated she had schizophrenia and said she "had symptoms for a long time and behaviors for an extended period." The administrator promised to investigate but provided no additional documentation.
The medication errors extended beyond psychiatric drugs. Staff repeatedly gave Resident 16 blood pressure medication when her vital signs fell below the physician's safety parameters. The drug metoprolol was ordered to be held if her blood pressure dropped below 100/60 or heart rate fell under 60 beats per minute.
Records show staff administered the medication 29 times in May and June when her blood pressure was too low, including readings as low as 98/55. They gave the drug twice when her heart rate was 59 beats per minute.
On multiple occasions, staff failed to check vital signs before giving medications. Heart rate measurements were missing on 17 shifts in May and June. Blood pressure readings were absent on 10 shifts during the same period.
The resident was also prescribed furosemide for fluid retention, to be given if she gained more than two pounds. Staff obtained her weight only 12 times out of 31 opportunities in May, missing a five-pound weight gain from 150 to 155 pounds between May 25 and May 29.
Care planning failures affected multiple residents. The facility failed to hold required care conferences for newly admitted patients within federal timeframes. Resident 21, admitted with a cervical fracture, had one care conference the day after admission but no follow-up meetings despite staying longer than 20 days.
Staff gave conflicting information about care conference requirements. The Social Service Director said meetings should occur within three days of admission, then at 14 days if the resident stays longer than 20 days, then every 90 days. The LPN Unit Manager said conferences happened within three days, as needed, and every 90 days. The Administrator acknowledged they should occur within seven days of completing the comprehensive assessment.
Resident 25, who had been at the facility since 2017, went six months without a care conference meeting. Her representative told inspectors the facility "used to have quarterly care conference meetings and that seems like it's not happening any longer."
The Social Service Director admitted she contacted family members only the day before scheduled conferences and made no attempt to reschedule when representatives couldn't attend.
Another resident, admitted with rib fractures, had no documented care conferences despite staying at the facility for weeks. Her representative was unaware if any care planning meetings had occurred.
Staff also failed to monitor residents after falls and medication refusals. Resident 51 slipped out of bed on March 14, 2024, prompting an investigation that called for neurological assessments. No such monitoring was documented in the days following the fall.
"After a fall staff were to monitor a resident twice a day," the Director of Nursing told inspectors. When asked to provide the neurological assessments for Resident 51, she offered no additional information.
Resident 33, prescribed the laxative Senna twice daily since January, missed 32 doses between May 1 and June 11. The LPN said the resident refused the medication but was unsure if she reported the refusals to the physician. Unit managers acknowledged staff were expected to notify doctors after every refusal but failed to do so consistently.
The violations occurred during a June 14, 2024 federal inspection. Highland House Nursing & Rehabilitation Center is located at 2201 NW Highland Avenue in Grants Pass.
The resident with the false schizophrenia diagnosis told inspectors she was no longer taking the antipsychotic medication. She remains at the facility with her actual diagnoses of anxiety and depression, conditions that went untreated while staff medicated her for a mental illness she never had.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland House Nursing & Rehabilitation Center from 2024-06-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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