ASHEVILLE, NC - State health inspectors identified serious breakdowns in medical communication and treatment protocols at Carolina Pines At Asheville, including a failure to follow up on specialist recommendations that left one resident without needed kidney stone treatment for over two months.
Delayed Urology Treatment Places Resident at Risk
The most significant finding involved a resident with kidney stones and a urinary stent who experienced repeated delays in receiving recommended follow-up care. The resident had been hospitalized in April 2024 for obstructing kidney stones with hydronephrosis, urinary tract infection, and sepsis—a life-threatening condition where the body's response to infection causes widespread inflammation.
During that hospitalization, a urologist placed a stent in the resident's ureter to allow urine drainage. The hospital discharge summary specifically instructed the facility to arrange urology follow-up within one to two weeks for surgery to remove the kidney stones and potentially exchange the stent.
The resident was seen by a urologist on May 16, 2024. The specialist ordered a CT scan to evaluate the size and location of the stones and instructed the facility to schedule a follow-up appointment after the scan to plan surgical treatment. However, the facility never scheduled the CT scan or the follow-up appointment. Medical records contain no documentation that the nursing staff or medical director were informed about the May 16 visit or the specialist's recommendations.
Between May and July, the resident experienced ongoing blood in the urine—a condition known as hematuria. Multiple urine cultures showed no bacterial growth, yet the resident received antibiotics intermittently during this period. The facility's nurse practitioner repeatedly noted in progress reports that a urology consultation was "pending," apparently unaware that the resident had already been seen in May.
It wasn't until July 18, 2024—more than two months after the initial urology visit—that the facility requested another urology appointment, which was scheduled for August 7. Surveyors discovered the lapse when they reviewed the facility's transportation schedule and contacted the urology office directly.
Medical Consequences of Treatment Delays
Kidney stones that obstruct the urinary tract create multiple health risks. When urine cannot drain properly, pressure builds in the kidney, causing hydronephrosis. Prolonged obstruction can result in permanent kidney damage and loss of kidney function. The presence of an indwelling stent, while necessary to maintain drainage, creates its own complications when left in place for extended periods.
According to medical protocols, stents typically require replacement or removal within specific timeframes to prevent complications. The urologist noted that patients with indwelling stents face an increased risk of recurrent infections. When combined with untreated obstructing stones, this creates a significant risk for repeated episodes of sepsis, which can be fatal in medically complex individuals.
The resident's history of sepsis from the original kidney obstruction made timely follow-up particularly critical. Sepsis occurs when infection triggers a cascade of changes that can damage multiple organ systems. Individuals who have experienced sepsis once are at elevated risk for subsequent episodes, especially when the underlying cause—in this case, kidney stones—remains untreated.
The ongoing hematuria documented in the medical record also warranted prompt investigation. While some blood in the urine can occur with kidney stones and stents, persistent bleeding requires evaluation to rule out other causes, including bladder tumors or stone movement that could cause additional obstruction.
Breakdown in Communication Systems
The inspection revealed fundamental failures in the facility's system for tracking and responding to specialist recommendations. When a nursing assistant accompanied the resident to the May 16 urology appointment, she reported giving the appointment paperwork to nursing staff upon return. However, no documentation of this visit appeared in the resident's electronic medical record, and the medical director stated he never received the specialist's notes or orders.
The facility's process required nursing staff to input physician orders into the resident's chart and provide referrals to the transportation scheduler. The transportation scheduler would then contact providers to arrange appointments and document them on a calendar. However, this system apparently lacked redundancies to ensure that specialist recommendations were communicated to the treating physicians and acted upon promptly.
Multiple staff members interviewed during the survey expressed awareness that the resident needed urology consultation but appeared unaware that such a visit had already occurred. The medical director and nurse practitioner both documented repeatedly in progress notes that urology consultation was needed, with the medical director ordering a urology consult in June, apparently not knowing the resident had been seen in May.
Incorrect Wound Dressing Creates Immediate Danger
Inspectors identified a second immediate jeopardy situation involving improper wound care for a resident with diabetic foot ulcers. A treatment nursing assistant applied a two-layer compression system intended for venous leg ulcers instead of the regular wrapping bandage ordered by the podiatrist.
Compression systems work by applying controlled pressure to improve circulation in specific conditions like venous insufficiency. However, they are contraindicated for diabetic ulcers and arterial disease because excessive pressure can restrict blood flow to tissues that already receive inadequate circulation due to diabetes-related vascular damage.
When surveyors observed the wound care procedure, they noted that the resident's toes on the affected foot turned dark purple after the dressing was applied—a clear sign of impaired circulation. When the dressing was removed and reapplied more loosely, normal color returned to the toes. On the opposite foot, removal of the compression dressing revealed dusky gray discoloration of the skin that had been covered, with a small purple area over a bony prominence.
The treatment assistant explained she had used the compression system because the box was labeled "Coban 2," and the physician's order specified "Coban"—a brand name for standard cohesive bandaging. She stated she thought the two-layer system in the box was what she was supposed to use. The assistant also acknowledged she did not check the resident's circulation after applying the dressings.
Medical protocols for diabetic wound care emphasize the importance of maintaining adequate blood flow to healing tissues. Diabetes damages both large and small blood vessels, reducing oxygen and nutrient delivery to the extremities. Any additional compression of blood vessels can tip the balance toward tissue death, expanding existing wounds or creating new ones. In severe cases, inadequate circulation can lead to gangrene requiring amputation.
The treatment assistant had discovered a new wound on the resident's right heel approximately ten days earlier but never reported it to nursing staff or obtained treatment orders. Instead, she applied iodine to the area daily without authorization. The podiatrist was not notified of the new wound and did not learn about it until the next scheduled office visit.
Additional Wound Care Deficiencies
For another resident with stage IV pressure ulcers, the same treatment assistant applied incorrect products during wound care observed by surveyors. Instead of using calcium alginate dressings as ordered, she applied collagen powder to one wound and medihoney to another. When interviewed afterward, she acknowledged feeling overwhelmed and stated she "could not remember everything" required for the resident's wound care.
Pressure ulcer treatment requires precise adherence to prescribed protocols because different wound care products serve specific purposes based on wound characteristics. Calcium alginate dressings absorb moderate to heavy drainage while maintaining moisture balance. Using incorrect products can delay healing or worsen wounds by creating inappropriate moisture levels or failing to address infection risk.
Privacy Protection Lapses
During the survey, an inspector observed an unattended wound care cart in a hallway with a resident's Treatment Administration Record visible on the computer screen. The screen displayed the resident's name, photograph, and current medications—private health information accessible to anyone passing by. The treatment assistant had walked away to answer a call light and forgot to activate the privacy screen.
Healthcare facilities must safeguard protected health information under federal HIPAA regulations. Electronic devices containing patient information require privacy screens that activate automatically after brief periods of inactivity, or staff must manually secure devices before leaving them unattended.
Incomplete Smoking Safety Assessments
Inspectors found that smoking safety assessments were not completed accurately or according to the required schedule. One resident's most recent assessment from April 2024 indicated he was an "independent smoker" requiring no supervision, yet his care plan classified him as a supervised smoker, and staff members confirmed they supervised his smoking at designated times.
For another resident, no smoking assessment had been completed since March 2023, despite facility policy requiring quarterly assessments. Staff members reported the resident smoked occasionally, but no current evaluation existed to determine his ability to smoke safely.
Accurate smoking assessments are essential for fire safety in nursing facilities. Residents with cognitive impairment, impaired judgment, or physical limitations may be unable to manage smoking materials safely, creating risks for themselves and others. Regular reassessment ensures that supervision levels adjust to changes in residents' functional status.
Immediate Jeopardy Removal Actions
The facility implemented corrective measures that convinced surveyors to remove the immediate jeopardy designations on July 26-27, 2024. For the communication breakdown, the facility revised its procedures for documenting and tracking outside appointments. Medical records staff now check designated boxes at each nursing station daily for appointment orders, review them during morning clinical meetings, and enter appointments on a dashboard accessible to the medical director and nurse practitioner.
The facility also audited all current residents to ensure the medical director was aware of upcoming appointments and that no other specialist recommendations had been overlooked.
For the wound care issues, the facility provided immediate re-education to all nursing staff on following physician orders precisely, removed the compression system products from treatment carts to prevent confusion, and reassigned wound care duties from nursing assistants to licensed nurses.
However, the facility remains out of compliance at lower severity levels while inspectors verify the effectiveness of these corrective measures over time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carolina Pines At Asheville from 2024-08-07 including all violations, facility responses, and corrective action plans.
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