The February 6 inspection revealed the rural Nevada facility failed to follow basic medical protocols when a nurse discovered what she called a "large slit" in Resident #5's left abdominal fold after a shower on January 28. Instead of measuring the wound, notifying the physician, or obtaining treatment orders, the LPN applied surgical tape strips and continued treating the injury through January 31 without authorization.
"The LPN was not acting within the LPN's scope of practice," Chief Nursing Officer confirmed to inspectors on February 5.
The nurse admitted her mistakes during the inspection. She acknowledged describing the skin tear as a "large slit" was improper documentation, confirmed she never measured the wound's dimensions, and failed to notify any physician about the injury. Most critically, she admitted providing wound care without a doctor's order violated her professional scope of practice.
"It was not within an LPN's scope of practice to provide wound care without a physician's order," the nurse told inspectors.
Nevada nursing standards require LPNs to report observations to appropriate personnel and obtain proper authorization before performing medical tasks requiring substantial judgment. The hospital's own job description mandates LPNs "note and initiate physician orders, verifying and clarifying conflicting or questionable orders when necessary."
Records show the facility had only one existing order for Resident #5 - Nystatin powder for a fungal condition, prescribed November 21. The nurse abandoned this prescribed treatment in favor of unauthorized wound closure strips.
Daily nursing notes from January 28 through January 30 documented the nurse's ongoing unauthorized treatment. On January 28, she noted monitoring the "large slit" closely with strips "intact." By January 30, the area had turned red and required new strips. The final entry stated strips were "coming off" and would be replaced before the resident left for a family visit.
The facility's documentation failures extended beyond the unauthorized treatment. Clinical records contained no wound measurements, no physician notifications, no treatment orders for the skin tear, and no care plan addressing the injury's management.
Meanwhile, Resident #3 experienced dramatic weight loss that staff documented but failed to address through proper care planning. The resident lost 5.1 percent of their body weight between December 13 and January 1, and 10.7 percent between November 4 and February 4.
A January 4 assessment confirmed the resident was not on any weight loss regimen. The registered dietitian noted the "significant weight loss of 5%" in quarterly documentation. A January 17 dietary note attributed the 5.2 percent monthly decline to pneumonia, medication changes, decreased appetite, and reduced overall intake.
Despite this documented pattern of concerning weight loss and identified contributing factors, the resident's comprehensive care plan dated January 8 contained no interventions or goals to address the significant weight change.
The LPN serving as long-term care coordinator confirmed on February 5 that Resident #3 "had significant weight loss and lacked a care plan to identify the goals and interventions to address the weight change." The chief nursing officer made an identical confirmation that morning, acknowledging the facility failed to develop proper care planning for the resident's documented decline.
Both violations represent what inspectors classified as "minimal harm or potential for actual harm" affecting "few" residents. However, the deficiencies highlight systematic failures in the facility's clinical oversight and professional nursing practice standards.
Battle Mountain General Hospital's policy manual, last reviewed in December 2017, requires individualized care plans appropriate to each resident's needs, strengths, limitations and goals. The policy mandates care plan re-evaluation whenever residents experience significant condition changes.
The facility operates as both a hospital and nursing home in Nevada's rural Lander County, serving a community of approximately 3,500 residents. Federal inspection records show the facility struggled to maintain basic documentation standards and professional practice boundaries during the winter months when both residents experienced their respective medical issues.
For Resident #5, the unauthorized wound treatment continued until the resident left for family visits, with no indication the facility ever obtained proper medical authorization or established appropriate wound care protocols. The resident's clinical record remained incomplete regarding the injury's resolution or ongoing treatment needs.
Resident #3's weight loss trajectory, if continued at the documented rate, could have led to severe nutritional complications. The facility identified multiple contributing factors including pneumonia and medication effects but failed to implement any systematic interventions to halt or reverse the decline.
Both cases illustrate the potential consequences when nursing facilities fail to follow established medical protocols and care planning requirements, leaving vulnerable residents without appropriate clinical oversight during critical health changes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Battle Mountain General Hospital from 2025-02-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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