Resident #51 missed 21 doses of gabapentin 800 milligrams over six days in May when the facility simply didn't get the medication. She was supposed to take it four times daily for nerve pain.
The woman complained of numbness in her legs and muscle spasms as doses piled up. After missing 14 doses, she was transferred to the emergency department at 2 a.m. on May 12. Hospital staff treated her acute pain with gabapentin and sent her back to the nursing home the same day.
But Premier Living still hadn't obtained the medication.
She missed three more doses on May 12 and returned to the emergency room that evening with worsening muscle spasms. Again, hospital staff treated her pain with gabapentin and discharged her back to the facility.
The facility let her miss four more doses before finally getting the medication from the pharmacy on May 13.
Federal inspectors found the medication failures put residents in immediate jeopardy during a July inspection. The problems extended beyond one resident's pain crisis.
Resident #46 also went without gabapentin when the facility failed to obtain her prescribed 800 milligrams twice daily for nerve pain. She missed 14 doses between May 10 and May 17.
The missed medication left her unable to sleep and struggling with anxiety, irritability, and nausea. Pain in her legs prevented her from completing her normal daily routine, according to the inspection report.
A third resident, #8, was prescribed the opioid medication Oxycodone/Acetaminophen 10/325 milligrams. The facility failed to obtain this medication from the pharmacy as well, resulting in multiple missed doses.
Inspectors interviewed facility staff, residents, the consultant pharmacist, a pharmacy quality assurance specialist, and physicians during their review. They examined medication records for 10 residents and found three had been denied their prescribed medications because the facility hadn't obtained them from the pharmacy.
The inspection narrative doesn't explain why Premier Living failed to get the medications or how long the procurement problems had been occurring. The facility's medication management system broke down completely for these residents during a two-week period in May.
For Resident #51, the consequences were immediate and severe. Her pain escalated from manageable with medication to requiring emergency medical intervention twice in 24 hours. Each time, hospital staff provided the exact medication her nursing home had failed to obtain.
The gabapentin she needed costs roughly $20 for a month's supply at most pharmacies.
Resident #46's experience illustrated how medication failures ripple through daily life. Her untreated nerve pain didn't just hurt - it disrupted her sleep, triggered anxiety, and left her unable to participate in activities that structured her days at the facility.
The facility received an immediate jeopardy citation, the most serious level of violation federal inspectors can issue. This designation means the problems created a situation where residents faced immediate risk of serious injury, harm, impairment, or death.
Premier Living operates at 106 Cameron Street in Lake Waccamaw, a small town in southeastern North Carolina. The facility serves residents requiring both short-term rehabilitation and long-term care.
The inspection occurred on July 2, more than a month after the medication crisis that sent one resident to the hospital twice. Federal regulations require nursing homes to ensure residents receive their prescribed medications as ordered by their physicians.
The missed doses represented a complete breakdown in one of the most basic responsibilities of nursing home care - making sure residents get the medications their doctors prescribed to manage pain, prevent complications, and maintain their health.
Resident #51's two emergency room visits in one day stand as a stark reminder of what happens when that system fails.
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.
Additional Resources
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