Decatur Health & Rehab: Immediate Jeopardy Violations - AL

The incident at Decatur Health & Rehab Center triggered immediate jeopardy violations that lasted nearly a month, from January 4 through February 1, 2025. Federal inspectors found the facility's failures put the resident at serious risk of heart attack and death.

The resident, identified as RI #497, had been admitted December 27 after a hospital stay for atrial fibrillation with rapid ventricular response. The patient had intact cognition and multiple heart conditions including chronic obstructive pulmonary disease and unspecified atrial fibrillation.

Licensed Practical Nurse #10 discovered the elevated heart rate at 1:24 PM on January 4 and immediately contacted the certified registered nurse practitioner. The provider gave clear instructions: check the heart rate manually twice daily, and if it doesn't go down, send the resident to the hospital.

But LPN #10 never rechecked the pulse before her shift ended at 6 PM.

"I should have entered a progress note to inform the oncoming staff and others of the resident's status, but did not," she told inspectors. "The concern of not documenting in the resident's progress notes about the resident's care and heart rate was no one would know that a problem had occurred."

She acknowledged the risk. "Not assessing the resident could put the resident at risk for a heart attack," she said. "The concern of her not taking the resident's heart rate after the order was given was the resident's heart rate could have gone up a lot more."

The nurse practitioner confirmed she had instructed staff to assess the resident and recheck the heart rate manually twice daily. "If the heart rate did not go lower to send the resident to the hospital," she said. "I did not know why the resident was not sent to the hospital until around 4:00 AM."

The medical director was blunt about the standard of care. "The resident should have been sent out for the heart rate of 142 if the resident was symptomatic," he told inspectors.

The night shift nurse, LPN #16, found the resident in distress just after midnight. Her progress note at 12:36 AM documented "difficulty breathing noted" and "labored breathing."

At 9:22 PM on January 4, someone had finally recorded another heart rate: 120 beats per minute. Still dangerously elevated, but no action was taken.

The resident wasn't transferred to the emergency room until 4:10 AM on January 5, after requesting to go to the hospital. By then, the patient was experiencing chest pain, shortness of breath, and a pulse between 120 and 150 beats per minute.

"Unable to catch breath. Unable to talk," the nurse documented.

The heart rate crisis exposed a second dangerous pattern at the facility. The same resident had been receiving digoxin, a high-risk heart medication that requires checking the pulse before each dose. Nurses had been giving the drug without monitoring heart rates at all.

Davis's Drug Guide identifies digoxin as high-risk and instructs nurses to monitor the pulse for one full minute before administering, holding the dose if the pulse rate drops below 60 beats per minute in adults.

On December 30, Registered Nurse #14 administered digoxin at 8 AM without checking the resident's heart rate. "I did not check the resident's heart rate because there were no doctor's orders to check the heart rate," she told inspectors. "There was no place to document the heart rate on the December 2024 medication administration record."

The medical director called this a basic nursing failure. "It was standard of practice to check the heart rate of a person receiving digoxin before administering the medication," he said. "It was just standard practice for the nurse to assess resident's heart rate before administering digoxin."

But the director of nursing disagreed. She told inspectors the standard was to "administer medication as ordered" and that heart rate assessment was only required "per doctor's order."

Licensed Practical Nurse #28 administered digoxin again on January 1 without checking the pulse, despite telling inspectors that "the standard of practice nurses use before administering digoxin was to check the apical pulse."

The facility's vital signs monitoring was equally chaotic. The resident had been ordered to have vital signs checked monthly, despite being a new admission with serious heart conditions. Multiple staff members said new admissions should have vital signs checked at least daily, with some saying every shift.

For five consecutive days after admission, from December 29 through January 2, there was no evidence the resident's vital signs were assessed at all.

"Newly admitted residents should have vital signs assessed at least daily," the director of nursing acknowledged. But the admission orders called for monthly checks with no parameters for when to notify providers of abnormal readings.

The nurse practitioner said she expected "vital signs to be assessed each shift for newly admitted residents." The house supervisor agreed: "newly admitted residents should have vitals assessed each shift until discharged."

The facility implemented an immediate jeopardy removal plan on February 1, requiring all 31 licensed nurses to receive education on proper order transcription, communication between shifts, and heart rate monitoring for high-risk medications. The plan identified 13 residents on digoxin and similar medications requiring vital sign monitoring.

But the violations extended beyond nursing care. In the kitchen, inspectors found frozen chicken thawing improperly in a prep sink with no running water, violating food safety standards. Two boiled eggs sat in a cooler without use-by dates, creating foodborne illness risks for all 100 residents receiving meals from the facility.

Outside, both dumpsters were left open with food-related trash scattered on the ground, creating conditions that could attract rodents and pests into the facility.

Essential kitchen equipment had been broken for years. The tilt skillet had been out of order for four years and was being used as a countertop. The double steamer stopped working in 2023. Two stove ovens had pilot light problems that prevented proper operation.

"If both went down, they would have a problem," the maintenance director acknowledged about the backup equipment situation.

A nurse also falsified medication records, documenting that she had administered insulin to a diabetic resident when she had not given the medication. Licensed Practical Nurse #27 "accidentally hit the wrong key" when documenting, she told inspectors, admitting she "did not follow facility policy for documentation."

Another nurse violated infection control protocols by handling medications with bare hands and using medical equipment on multiple residents without cleaning or disinfecting between uses.

The immediate jeopardy designation was removed February 2 after the facility implemented corrective measures, but inspectors continued monitoring to ensure substantial compliance with federal regulations.

The case illustrates how multiple system failures can compound to create life-threatening situations for vulnerable nursing home residents, from basic nursing protocols to equipment maintenance to infection control.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Decatur Health & Rehab Center from 2025-02-03 including all violations, facility responses, and corrective action plans.

Additional Resources

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