NEW HOPE, MN - A July 2024 federal inspection at North Ridge Health and Rehab uncovered significant deficiencies in medication management, dialysis care monitoring, and basic medical recordkeeping that placed vulnerable residents at risk for serious health complications.
Critical Medication Errors Endanger Resident with Low Blood Pressure
The facility repeatedly administered blood pressure medication to a resident with severe cognitive impairment despite documented blood pressure readings that fell outside physician-ordered parameters. The resident, who suffered from hypertension and end-stage renal disease, was prescribed Midodrine three times daily only when their systolic blood pressure dropped below 100 or diastolic below 60.
Medical records revealed nursing staff administered the medication on multiple occasions when blood pressure readings were well above these thresholds. On July 11, 2024, a registered nurse gave the morning dose after recording a blood pressure of 119/72 - significantly higher than the parameters requiring medication. When questioned, the nurse stated "he had taken a different BP reading, but could not produce it or remember it when asked."
Administering blood pressure medication when not clinically indicated poses serious risks. Midodrine increases blood pressure by constricting blood vessels. When given to patients whose blood pressure is already within normal ranges, it can cause dangerous spikes leading to stroke, heart attack, or organ damage. The facility's documentation policy notably lacked specific guidance on verifying blood pressure readings before administering medications with parameters.
Dialysis Monitoring Failures Compromise Patient Safety
Three residents receiving life-sustaining dialysis treatments experienced systematic failures in post-treatment monitoring between May and July 2024. Required post-dialysis assessments were missing for approximately 60% of treatments across the three residents reviewed.
One resident underwent dialysis on 15 occasions during the review period, yet post-dialysis assessments were absent for eight treatments. Another resident lacked assessments for five of 15 treatments. When assessments were documented, critical information including current weights and vital signs was frequently missing.
Post-dialysis monitoring is essential for detecting potentially fatal complications. Dialysis rapidly removes fluid and toxins from the blood, which can cause dramatic shifts in blood pressure, electrolyte imbalances, and bleeding at access sites. Without timely assessment, complications including cardiac arrhythmias, seizures, and hemorrhage can go undetected until they become life-threatening.
Most troubling was the case of a resident whose dialysis access device was surgically removed during a June hospitalization for infection. Despite no longer requiring dialysis, staff continued documenting completion of dialysis-related tasks for nine days after the resident returned, including checking for "thrill and bruit" at an access site that no longer existed.
Seven Months of False Documentation for Non-Existent Medical Condition
For seven consecutive months, nursing staff documented providing colostomy care every shift to a resident who did not have a colostomy. The resident had a urostomy for urine collection following bladder cancer surgery, but never had the bowel surgery that would necessitate colostomy care.
From December 2023 through July 2024, staff signed off on providing colostomy care three times daily - over 600 false entries in the medical record. When investigators pointed out the discrepancy, the facility's leadership could not explain why staff continued documenting care for a non-existent condition. The director of nursing admitted "they did not have an explanation as to why staff had continued to sign off on colostomy care for 7 months."
False documentation undermines the entire medical record's integrity and can lead to inappropriate medical decisions. Future providers relying on these records might make treatment decisions based on the false belief the resident had a colostomy, potentially ordering unnecessary procedures or medications.
Additional Issues Identified
The inspection also revealed a resident on long-term antibiotics for a serious spinal infection went over a month without required infectious disease follow-up, with the appointment finally scheduled only during the inspection. Vital signs monitoring for residents with heart failure was inconsistently performed despite physician orders for daily monitoring, and one resident with malnutrition who had experienced significant weight loss went over a month without required weight monitoring. Additionally, a resident with incontinence and history of pressure ulcers was left in a wheelchair for over four hours without repositioning or toileting assistance.
These violations reflect systematic breakdowns in basic nursing care protocols and documentation practices that are fundamental to resident safety and quality care delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Ridge Health and Rehab from 2024-07-11 including all violations, facility responses, and corrective action plans.
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