SPOKANE, WA - A federal inspection at Gardens On University revealed critical failures in mental health care that contributed to a stroke patient's severe physical and psychological decline over several months.
Depression Screening Ignored Despite Clear Warning Signs
The case involved a resident who was admitted in December 2024 following a stroke that left them with right-sided weakness and paralysis. Within days of admission, staff completed a PHQ-9 depression screening that revealed a score of 17 - indicating moderately severe depression symptoms. Despite this clear warning sign, facility staff failed to initiate appropriate mental health interventions.
Federal regulations require nursing homes to provide necessary behavioral health care and services. The inspection found that after identifying the depression symptoms, facility staff should have immediately discussed behavioral health services with the resident or their family and documented this conversation in the medical record. This critical step never occurred.
Medical Provider's Mental Health Order Went Unnoticed
The situation escalated when the resident began exhibiting increasingly concerning behaviors. Starting in mid-December, nursing notes documented frequent medication refusals, argumentative behavior, and resistance to basic care including repositioning to prevent pressure sores.
On January 6, 2025, the facility's Advanced Registered Nurse Practitioner wrote a specific order for a "Behavioral Health Consult for behaviors; trying to fall out of bed; refusing meals; combative with staff; pulling on foley catheter; refusing care." This order was meant to address the resident's deteriorating mental state and disruptive behaviors.
However, inspection interviews revealed that key staff members were unaware this order had been written. The Social Services Director, Administrator, and Resident Care Manager all stated they had not been notified of the behavioral health evaluation order and confirmed that the assessment never took place.
Physical Health Deteriorated Alongside Mental Decline
The resident's refusal to participate in care had immediate physical consequences. Nursing progress notes documented extensive problems with medication adherence, particularly concerning antibiotics prescribed to treat a bone infection in their left foot. Records showed the resident refused antibiotic medications on 10 of 46 scheduled administrations during December 2024.
More concerning was the resident's resistance to repositioning - a basic care intervention essential for preventing pressure sores. The resident refused repositioning during 11 of 80 nursing shifts, despite staff attempts to educate them about the importance of position changes for wound prevention.
By January 2025, the consequences became severe. Wound care notes documented that the resident had developed new pressure sores, including one on their right heel. An existing wound on their left second toe had deteriorated to the point where bone and tendon were exposed. The wound specialist noted a "high probability of osteomyelitis" (bone infection) and described the overall wound status as requiring urgent family discussion about care goals.
Nutritional Intake Plummeted Amid Care Refusals
The resident's mental health crisis also manifested in severe eating difficulties. Nursing notes from January documented repeated meal refusals, with staff noting the resident would "turn their head away and state, not now" when offered food or drinks. On one occasion, the resident pushed their food tray onto the floor.
Weight records showed a dramatic decline from an admission weight of 135.8 pounds to a low of 120 pounds by January 10, 2025 - representing a 12-pound weight loss that prompted medical intervention including appetite stimulants and nutritional supplements.
The Advanced Registered Nurse Practitioner documented concerns about "inadequate oral intake with subsequent 12-pound weight loss since admit" and noted "poor insight and significantly impaired judgment with presence of delusional thinking."
Care Planning Failed to Address Behavioral Components
Review of the resident's care plan revealed additional systemic failures. While the plan was updated in late December to note that the resident was "resistive to care," it lacked personalized interventions to address this resistance. A January update added a focus for "experiencing hallucinations, delusions, and/or paranoia" attributed to a urinary tract infection, but no behavioral health interventions were implemented even after the UTI was successfully treated.
Federal standards require nursing homes to develop comprehensive care plans that address all aspects of a resident's condition, including behavioral and mental health needs. The care plan's failure to incorporate specific interventions for the resident's depression diagnosis, positive depression screening, or ordered mental health evaluation represented a significant gap in person-centered care.
Communication Breakdowns Compounded Problems
Inspection interviews revealed concerning communication failures within the facility. The Social Services Director was unaware of both the positive depression screening completed by their own assistant and the medical provider's behavioral health order. The Administrator confirmed they had not been notified of the mental health evaluation order and acknowledged that the behavioral health assessment never occurred.
Standard nursing home protocols require interdisciplinary communication about significant changes in resident condition and new medical orders. The failure of multiple staff members to be aware of critical mental health needs suggests systemic communication problems that may affect other residents' care.
Family Intervention Led to Hospital Transfer
The resident's family became increasingly concerned about their loved one's dramatic physical and mental decline. According to the inspection report, family members had never observed depression symptoms or food refusal behaviors prior to this admission. Their concerns ultimately led them to request evaluation at a local hospital on December 29, 2024, which revealed the urinary tract infection.
By January 30, 2025, the family's ongoing concerns about their loved one's deteriorating condition prompted them to request another hospital transfer. The resident remained hospitalized and did not return to the facility, according to inspection documentation.
The family member interviewed during the inspection emphasized their primary concern was the resident's "mental decline" and stated the resident "seemed to get so much worse" during their stay at the facility.
Dental Care Also Inadequately Managed
The inspection identified additional care coordination failures related to dental services. The resident complained of mouth pain from ill-fitting upper dentures, and a December 17 dental examination revealed an open sore where the denture rubbed against jaw tissue. The dentist recommended denture adjustment, but facility staff failed to follow through on scheduling the appointment with a denturist.
The unresolved dental problem likely contributed to the resident's eating difficulties and overall decline in condition. Properly fitted dentures are essential for adequate nutrition, especially for stroke patients who may already have swallowing difficulties.
This case demonstrates how mental health care failures can cascade into multiple aspects of a resident's wellbeing, affecting physical health, nutrition, wound healing, and overall quality of life. The resident's story underscores the critical importance of comprehensive behavioral health services in nursing home care and the need for effective communication systems to ensure medical orders are properly implemented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens On University, The from 2025-02-21 including all violations, facility responses, and corrective action plans.
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