LAKE WACCAMAW, NC - Federal inspectors found immediate jeopardy violations at Premier Living and Rehab Center after the facility failed to notify physicians when residents missed critical medications, resulting in severe pain and withdrawal symptoms.
Critical Medication Lapses
The July 2024 inspection revealed that three residents experienced significant health consequences when the facility failed to follow basic medication management protocols. The most severe case involved a resident who missed 21 doses of gabapentin over six days without any physician notification.
Gabapentin is a nerve pain medication that requires careful monitoring due to its potential for withdrawal symptoms when discontinued abruptly. The affected resident experienced pain levels reaching 10 out of 10, along with numbness in her legs and muscle spasms during the period when doses were missed.
A second resident missed 14 doses of gabapentin over eight days, leading to sleep disturbances, anxiety, irritability, nausea, and inability to maintain normal daily activities due to leg pain. Again, no physician was contacted about the missed medications.
Antibiotic Mix-Up Creates Additional Risk
The facility's medication errors extended beyond gabapentin. Inspectors documented that one resident received 14 doses of the wrong antibiotic following a hospital discharge. The resident was prescribed Augmentin, a combination antibiotic containing both amoxicillin and clavulanate, but received only amoxicillin.
This substitution represents a significant clinical error, as the two medications have different bacterial coverage and effectiveness. Clavulanate extends amoxicillin's effectiveness against resistant bacteria, making the combination essential for certain infections.
Medical Protocol Violations
Standard medical practice requires immediate physician notification when prescribed medications are missed, particularly for drugs like gabapentin that can cause withdrawal symptoms. Healthcare facilities must maintain communication protocols to ensure continuity of care and prevent adverse outcomes.
The medication administration record should trigger alerts when doses are missed, and nursing staff should contact prescribing physicians within specified timeframes. These protocols exist specifically to prevent the type of suffering documented at Premier Living.
Pain management medications require especially careful monitoring because missed doses can lead to breakthrough pain, increased anxiety, and potential complications that may require emergency intervention or medication adjustments.
Widespread Communication Failures
The inspection findings indicate systemic problems with physician communication at the facility. Three out of ten residents reviewed during the inspection experienced medication-related issues where proper notification protocols were not followed.
This pattern suggests the facility lacks adequate systems to track missed medications and ensure appropriate medical oversight. Federal regulations require nursing homes to maintain physician communication standards that protect resident health and safety.
Regulatory Response
The Centers for Medicare & Medicaid Services classified these violations as immediate jeopardy, the most serious level of citation available. This classification indicates that the facility's practices created a situation where residents faced immediate risk of serious injury, harm, or death.
Immediate jeopardy findings typically result in enhanced oversight, mandatory correction plans, and potential financial penalties. The facility must demonstrate sustained compliance with medication management protocols to avoid further regulatory action.
Industry Standards for Medication Safety
Professional nursing standards require facilities to maintain accurate medication records, monitor for missed doses, and establish clear communication pathways with physicians. These protocols become especially critical for medications affecting pain management and neurological function.
The gabapentin medication involved in these cases requires particular attention due to its mechanism of action on nerve pathways. Sudden discontinuation can trigger withdrawal symptoms including increased pain sensitivity, anxiety, and sleep disturbances that may persist for days or weeks.
Federal inspection reports provide detailed documentation of care deficiencies and required corrections. Families and potential residents can access these reports through the Medicare.gov nursing home compare database to evaluate facility safety records and compliance history.
The full inspection report contains additional details about the facility's response to these violations and required corrective measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Premier Living and Rehab Center from 2024-07-02 including all violations, facility responses, and corrective action plans.
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