LAKE WACCAMAW, NC - Federal inspectors cited Premier Living and Rehab Center for immediate jeopardy violations after discovering widespread medication errors that resulted in multiple emergency department visits and potential harm to residents during a July 2024 survey.
Serious Medication Errors Trigger Emergency Response
The most severe violations centered on the facility's failure to prevent significant medication errors affecting nine of ten residents reviewed by inspectors. These errors included administering incorrect doses of powerful psychiatric medications and failing to provide essential pain management drugs for extended periods.
In one of the most concerning cases, a resident received six doses of haloperidol at 20 milligrams instead of the prescribed 4 milligrams total daily dose. Haloperidol is an antipsychotic medication that, when administered at such elevated levels, can cause serious adverse effects including sedation, movement disorders, and respiratory difficulty. The resident experienced an elevated pulse and shortness of breath, requiring emergency department evaluation on March 14, 2024.
The medication error occurred when nursing staff incorrectly transcribed the hospital discharge order. The discharge summary indicated the resident should receive "2 tablets of 2 mg at bedtime," but staff entered "20 mg at bedtime" into the facility's computer system. Multiple nurses administered the incorrect dose over six consecutive days without questioning the unusually high amount.
Additionally, the same resident was not administered carvedilol, a heart medication prescribed twice daily, for 25 doses between admission and emergency department visit. This omission had the potential for serious cardiovascular complications in a resident with congestive heart failure and atrial fibrillation.
Pain Management Failures Lead to Emergency Visits
Two residents experienced severe consequences when the facility failed to obtain gabapentin, a medication prescribed for nerve pain. One resident missed 21 doses over six days in May 2024, while another missed 14 doses over eight days during the same period.
The first resident reported constant pain at a level of 10 out of 10, along with numbness in her legs and muscle spasms. The withdrawal symptoms became so severe that she requested emergency transport twice on May 12, 2024. During both hospital visits, she received gabapentin and was discharged back to the facility with instructions to continue the medication four times daily.
Despite these emergency interventions, the facility continued to lack the medication. The resident missed four additional doses after returning from her second emergency department visit before staff finally obtained the prescription.
The second resident experienced increased pain levels of 8-9 out of 10, trouble sleeping, anxiety, irritability, and nausea during the period without medication. Staff reported she was unable to complete her normal routine due to pain in her legs and exhibited behavioral changes including increased agitation.
Antibiotic Treatment Compromised for Infected Wound
A resident with an infected stage 4 pressure ulcer failed to receive critical antibiotic therapy when nursing staff could not maintain intravenous access. The resident missed six doses of IV Rocephin and seven doses of IV Daptomycin prescribed to treat the severe wound infection.
When the resident's IV infiltrated on March 15, 2024, multiple nurses attempted unsuccessfully to restart it over several days. Rather than seeking immediate alternative solutions such as a PICC line placement, staff allowed the resident to go without antibiotic treatment. The resident was subsequently hospitalized, and discharge records indicated suspected sepsis likely centered around the large stage 4 pressure ulcer with possible bone infection.
Systemic Problems with Medication Management
Inspectors identified broader systemic issues with the facility's medication management processes. Staff demonstrated confusion about procedures for reordering medications, particularly controlled substances like gabapentin. Multiple nurses interviewed stated they believed they simply had to wait when medications were unavailable, rather than taking proactive steps to obtain them.
The facility's consultant pharmacist had identified ongoing problems with medication availability but reported limited follow-through on recommendations. Staff lacked comprehensive understanding of the processes needed to ensure continuous medication supplies, particularly for residents requiring specialized prescriptions.
Additional Medication Errors Documented
Beyond the immediate jeopardy violations, inspectors found additional medication errors affecting several residents:
- One resident received 14 doses of amoxicillin instead of the prescribed amoxicillin-clavulanate combination antibiotic for treating sepsis and urinary tract infection - Another resident missed 34 doses of an antidepressant medication over multiple weeks - A resident prescribed medication for tardive dyskinesia missed 23 doses when staff continued documenting administration despite the medication being unavailable - Blood pressure medication was administered outside of prescribed parameters on eight occasions
Staffing and Training Deficiencies
The inspection revealed significant staffing challenges that contributed to the medication errors. The facility failed to provide required eight-hour registered nurse coverage on 17 days over a four-month period, despite maintaining a census of more than 60 residents.
Staff training records showed gaps in essential education areas including medication management, infection control, and dementia care. When the previous staff development coordinator resigned, training documentation was reportedly lost, leaving the facility without evidence that required annual training had been completed.
Care Planning and Assessment Issues
Inspectors found the facility failed to complete required resident assessments within regulatory timeframes. Five admission assessments and 14 quarterly assessments were completed late, some by several weeks. These delays affected care planning and potentially compromised the facility's ability to identify and address changing resident needs.
Several residents lacked comprehensive care plans addressing identified needs such as nutrition, pain management, and fall prevention. In some cases, care plans were never developed despite assessment findings indicating the need for specific interventions.
Infection Control and Safety Concerns
Additional violations included improper infection control practices during wound care procedures and failure to maintain adequate infection surveillance programs. Staff were observed not following enhanced barrier precautions during treatment of a resident with a stage 4 pressure ulcer.
The facility also failed to properly store and dispose of medications, with expired drugs found throughout medication carts and storage areas. Some medications requiring refrigeration were stored at room temperature, potentially compromising their effectiveness.
Regulatory Response and Corrective Actions
Federal inspectors declared immediate jeopardy beginning with the first medication error on March 14, 2024, and continuing through May 2024 as additional serious violations were discovered. The immediate jeopardy status was removed on June 16, 2024, after the facility implemented acceptable corrective measures.
The facility reported cases to Adult Protective Services and law enforcement as required when neglect allegations were substantiated. All affected residents or their representatives were notified of the incidents.
Premier Living and Rehab Center must demonstrate sustained compliance with federal regulations and implement comprehensive monitoring systems to prevent future medication errors and ensure resident safety. The facility remains subject to ongoing oversight and potential enforcement actions if deficiencies recur.
The violations underscore the critical importance of proper medication management systems, adequate staffing levels, and comprehensive staff training in nursing home operations. When these fundamental safeguards fail, vulnerable residents face serious health consequences that can be life-threatening.
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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