Foley Center: Resident Death After Breathing Crisis - NC

Resident 278 died three days later of acute respiratory failure, influenza A, and bacterial pneumonia.

On the morning the crisis began, Medication Aide 1 arrived at 7:00 am to find Nurse 2 telling her that Resident 278 "was not doing well." When she checked on the resident, she found oxygen levels in the high 70s and low 80s — well below the normal range of 92 to 100 percent. The resident was struggling to breathe and asking for help.

The aide immediately got the Director of Nursing, who instructed her to put the resident on oxygen and continue monitoring. But as the hours passed, the resident's condition didn't improve. Her oxygen levels remained in the 80s throughout the shift.

"MA 1 told the DON multiple times during her shift about Resident 278 struggling to breathe, low oxygen saturation levels, and how she felt Resident 278 needed to be sent to the hospital but no one would listen to her," inspectors found.

The aide continued reporting her concerns until 4:47 pm, when the resident's representative arrived and removed her from the facility. No medical provider was ever notified during those nine critical hours.

At the hospital emergency department, Resident 278 was immediately diagnosed with influenza A and bronchitis. She had an elevated white blood cell count indicating infection and was given IV fluids, steroids, and breathing treatments. She was admitted to the hospital but later developed acute hypoxemic respiratory failure and died on comfort care.

The certificate of death listed the immediate cause as acute hypoxemic respiratory failure, influenza A, and bacterial pneumonia.

Federal inspectors found the facility had violated regulations requiring notification of medical providers when residents experience changes in condition. The violation was classified as immediate jeopardy — the most serious level indicating risk of death or serious harm.

During interviews, Medication Aide 1 told inspectors she "felt as though Resident 278 had been neglected because the DON had not allowed her to send Resident 278 to the hospital."

The facility's Social Worker agreed, telling inspectors that failing to notify a medical provider when a resident has low oxygen saturation and difficulty breathing "could be considered neglect."

But the Administrator took a different view. She told inspectors she "would not consider, not notifying a medical provider about a change in condition and not performing an assessment for a resident with a change in condition, to be neglect but instead a miscommunication."

The crisis had been building for days. Two days earlier, the resident's representative had requested a chest X-ray when Nurse 1 observed the resident had a cough, congestion, and decreased appetite. The Nurse Practitioner saw the resident the next day but decided against the X-ray, instead ordering medication to break up mucus and nebulizer breathing treatments.

On the morning of the emergency, multiple staff members were assigned to care for Resident 278, but the record shows a pattern of inadequate assessment and communication failures.

Nurse 11, assigned to the resident that day, told inspectors she "was unable to remember Resident 278 or any events that occurred" during her shift. No nursing progress notes were entered by Nurse 11.

Nurse Aide 1, also assigned to the resident, recalled that Resident 278 "had complained about hurting in her chest, could hardly talk because she was short of breath and was more tired than usual." But she couldn't remember if she had taken any vital signs or whether the resident had eaten or drunk anything.

No vital signs were documented for Resident 278 on the day of the crisis.

The facility's standing orders, reviewed by the Medical Director, specified that if a resident experienced shortness of breath, oxygen could be administered and the Medical Director should be notified of the change in condition. This protocol was not followed.

The Social Worker, who was present when the resident's representative arrived to remove her, observed that Resident 278 "appeared very sick" and was "sleepy and appeared out of it." She said Medication Aide 1 was in the process of calling the on-call provider when the representative arrived, but the representative refused to wait and insisted on taking the resident to the hospital immediately.

The Social Worker offered the representative an emergency oxygen tank for transport, but they declined, saying they were going straight to the emergency room.

The Nurse Practitioner who had seen Resident 278 two days earlier told inspectors she "never received any additional notification that Resident 278 had continued to have respiratory issues" and that "a medical provider should have been notified."

The Medical Director said he was unaware that Resident 278 had been taken to the emergency department and later died. He told inspectors that "a medical provider should have been notified because Resident 278 may have needed to be transferred to the hospital."

Even the Administrator, who had initially characterized the situation as a miscommunication rather than neglect, admitted she was unaware that Resident 278 had been transferred to the hospital and later died.

Hospital records showed the severity of the resident's condition upon arrival. She tested positive for influenza A, had an elevated white blood cell count, and required immediate intervention with steroids, IV fluids, and breathing treatments.

Her condition continued to deteriorate in the hospital. Within hours, she was struggling to maintain oxygen saturation above 91 percent despite supplemental oxygen. A chest X-ray showed pneumonia, and she was placed on antibiotics.

By the next day, she required 6 liters of oxygen per minute via nasal cannula. The hospital death summary revealed she had developed acute hypoxemic respiratory failure with a superimposed bacterial infection, including MRSA.

Due to her weak cough and overall debility, the representative placed her on comfort measures. She received inpatient hospice services and died with her representative at bedside.

The facility's Infection Preventionist told inspectors there had been no influenza or COVID outbreaks in 2024, and was unable to find any influenza testing results for Resident 278 at the facility.

In addition to the failure to notify medical providers, inspectors found the facility had failed to conduct proper abuse and neglect investigations. In one case, a nurse aide was allowed to finish her entire shift after another aide witnessed her with her hand raised toward a resident's face in what appeared to be a threatening manner.

The facility also inadequately investigated an allegation that someone had fraudulently used a resident's debit card information, failing to interview key staff members who had worked with the resident around the time of the alleged theft.

Federal inspectors validated the immediate jeopardy removal after the facility implemented emergency training for all staff on recognizing and responding to changes in resident condition. The facility audited all current residents and found two others who had experienced acute changes in condition, but confirmed that providers had been properly notified in those cases.

The violations occurred at The Foley Center at Chestnut Ridge, a nursing facility operated at 621 Chestnut Ridge Parkway in Blowing Rock. The facility's response to the crisis that led to Resident 278's death highlighted systemic failures in communication, assessment, and emergency response protocols that federal regulators determined put other residents at risk of serious harm or death.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for The Foley Center At Chestnut Ridge from 2024-07-03 including all violations, facility responses, and corrective action plans.

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