LACEY, WA - Federal inspectors found immediate jeopardy violations at Roo-lan Healthcare Center after emergency response system failures contributed to a resident's death and unsafe transport practices resulted in another resident requiring toe amputation.
The August 19, 2024 inspection revealed critical breakdowns in communication systems that prevented nursing staff from responding quickly to medical emergencies, with one incident resulting in an 8-9 minute delay in reaching a choking resident.
Communication System Breakdown During Medical Emergency
The most serious violation involved a resident with Parkinson's disease, chronic obstructive pulmonary disease, dementia, and severe swallowing difficulties who experienced a fatal choking incident. The resident, who was on aspiration precautions and required assistance with meals, began vomiting while lying in bed after lunch.
According to staff interviews, certified nursing assistant Staff E witnessed the resident vomiting three times and noticed the resident's skin color change to bluish around the mouth with abnormal breathing patterns. Despite these clear signs of respiratory distress, critical delays occurred in summoning nursing help.
Staff F, another nursing assistant, reported being unable to locate a nurse and stated "she was on break or something." Rather than using the facility's walkie-talkie communication system, Staff F sent a text message to the assigned nurse about the vomiting. The facility's Resident Care Manager later confirmed that when there was "a change in a resident's respiratory status or bluish color around the residents mouth it was emergent and needed immediate response."
The communication breakdown proved fatal. By the time nursing staff arrived approximately 8-9 minutes later with suction equipment, the resident had already died. Staff C, the Resident Care Manager, found the resident "already gone and yellow in color" despite attempts at oral suctioning.
Medical Significance of Response Delays
Aspiration events require immediate intervention to prevent fatal outcomes. When residents with severe dysphagia vomit while lying down, the risk of aspirating stomach contents into the lungs creates a life-threatening emergency. The bluish discoloration around the mouth (cyanosis) indicates oxygen deprivation, signaling that immediate airway clearance and positioning are critical.
The facility's own policies emphasized that "timely intervention to relieve obstruction is imperative to offset complications" for foreign body airway obstruction management. Medical protocols require residents at risk for aspiration to be positioned upright immediately and have airways cleared through suctioning within minutes of distress.
The resident's medical history made rapid response even more crucial. With documented chronic obstructive pulmonary disease and severe oropharyngeal dysphagia, any respiratory compromise represented an immediate threat to life. The Speech Language Pathologist had specifically noted staff reports of "coughing with puree intake when puree was separated, and a thin layer of liquid was present," indicating ongoing aspiration risk.
Systemic Communication Failures
Investigation revealed widespread problems with the facility's emergency communication system. Multiple staff members were observed working without walkie-talkies, which were supposed to be standard equipment for all personnel.
Staff E reported his walkie-talkie "was not charged and not functioning" during the emergency. Agency staff, who comprised a significant portion of the workforce, were not issued communication devices at all. One agency certified nursing assistant stated they had worked at the facility for two weeks without receiving a radio.
The facility Administrator acknowledged that "walkie talkies were the method intended to be used and were not used as expected" and confirmed the facility "did not have the ability to overhead page from resident rooms."
Transport Safety Violation Results in Amputation
In a separate incident, unsafe wheelchair transport practices led to a resident requiring surgical amputation of their left big toe. Resident 1, who had end-stage renal disease and required regular dialysis transport, was injured during loading onto the facility's transport bus.
The maintenance director, who was transporting the resident alone due to staffing shortages, placed the wheelchair-bound resident facing forward onto the lift platform - contrary to facility policy requiring residents to face away from the vehicle during loading. The resident's foot slipped off the footrest and became trapped under the rising platform.
Due to the resident's loss of sensation in both legs from their medical conditions, they were unable to alert staff that their foot was caught. The crushing injury resulted in a fractured toe requiring emergency surgery and amputation.
The maintenance director acknowledged the error, stating "the facility had two staff go on the bus with the resident the previous two times" but "on this occasion to/from dialysis, we were short staffed, and I volunteered to pick him up on this day by myself. I wished I had not."
Regulatory Standards and Required Improvements
Federal regulations require nursing facilities to maintain effective communication systems that ensure rapid response to medical emergencies. The Centers for Medicare & Medicaid Services cited the facility under F684 for failing to provide timely assessment and treatment by qualified personnel when delays in locating nursing staff occurred due to lack of a working emergency response system.
The facility was also cited under F689 for failing to ensure residents were free from avoidable accidents during transportation. Proper wheelchair transport protocols require adequate staffing, proper positioning of residents, and continuous visual monitoring of extremities during mechanical lifting operations.
Industry standards mandate that all staff, including agency personnel, have immediate access to communication devices during their shifts. Emergency response protocols must be practiced regularly, and equipment must be maintained in working order at all times.
Facility Response and Corrections
Following the inspection, Roo-lan Healthcare Center implemented immediate corrective measures. Investigators verified that all staff were wearing walkie-talkies and confirmed re-education had been provided on emergency response plans.
The facility removed the immediate jeopardy designation after demonstrating an effective system was in place to safeguard residents requiring immediate response. However, the violations highlighted systemic issues that required comprehensive policy and training updates.
Staff interviews revealed that some employees "wouldn't wear" their communication devices and that agency staff integration remained problematic. The facility's Administrator acknowledged that transportation procedures needed strengthening to prevent similar accidents.
Implications for Resident Safety
These violations illustrate how communication failures and inadequate safety protocols can have devastating consequences in nursing home settings. Residents with complex medical conditions depend on immediate professional response when emergencies occur.
The death of the choking resident demonstrates the critical importance of functioning emergency communication systems and proper staff training. Similarly, the transport injury shows how deviations from safety protocols, particularly during staffing shortages, can result in preventable harm.
Both incidents occurred despite the facility having written policies addressing these situations, highlighting the gap between policy development and consistent implementation. The involvement of agency staff without proper equipment or training compounds these challenges.
Federal regulations exist specifically to prevent these types of incidents through mandatory safety systems and protocols. When these safeguards fail, vulnerable residents face increased risks of serious injury or death from otherwise manageable situations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roo-lan Healthcare Center from 2024-08-19 including all violations, facility responses, and corrective action plans.
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