Southfield Wellness: Critical Lab Delays, Call Waits - IA

Resident #55 had moderately impaired cognition and required substantial assistance with mobility. The resident had heart failure, high blood pressure, irregular heartbeat, diabetes and acute kidney failure, according to a federal inspection completed in March.

An advanced registered nurse practitioner ordered lab work and a chest X-ray for Resident #55, noting the resident "may benefit from evaluation by Hospice."

The facility received the lab results on a Sunday at 1:08 AM. The results showed multiple abnormalities indicating serious problems: elevated infection markers, low red blood cell counts, impaired kidney function, and a brain natriuretic peptide level of 7,919 — more than 17 times the normal range. High BNP levels indicate heart failure, kidney failure or other serious conditions.

Staff faxed the abnormal results to the nurse practitioner for review.

The chest X-ray showed an enlarged heart, lung congestion and fluid around the lungs. Those results were also faxed to the practitioner.

Resident #55 died the following Tuesday at 11:07 AM.

The nurse practitioner didn't review the critical lab results until after the resident had died. She signed off on the chest X-ray results the day after the resident's death.

A communication form revealed the practitioner finally reviewed the lab results and had her nurse call the facility Monday at 4:52 PM — more than three days after the facility received them. The facility nurse reported Resident #55 had lost two pounds and was "doing okay." The form showed no additional medical orders regarding the abnormal results.

The facility's nurse consultant confirmed the practitioner didn't review the lab results until days later and failed to follow up on the chest X-ray results until after the resident died. The consultant said the facility was working with the practitioner on "her timeliness of addressing concerns" and had held multiple meetings about the issue.

The practitioner told inspectors she wasn't working over the weekend and that a hospitalist was covering for her. She said she returned to work and reviewed the labs then, having her nurse call the facility. When asked about the chest X-ray, she said she didn't review those results that week and couldn't locate them in the chart. She said she usually received copies of results that someone would scan into the chart, and she found the chest X-ray results in her clinic folder the following Thursday.

The facility's policy requires staff to "promptly notify" physicians of critical lab results and abnormal radiology findings. If the attending physician isn't available, staff should contact the medical director. The nurse consultant said critical lab values should be reported immediately and non-critical abnormal labs within 24 hours.

Meanwhile, residents throughout the facility waited dangerous lengths of time for basic care.

Resident #46, who has paralysis on one side of his body and uses a wheelchair, told inspectors staff took 30 minutes to an hour to answer call lights during afternoon and evening shifts. When his call light pendant broke, it wasn't replaced, forcing him to yell for help.

Call light records showed Resident #46 waited 37 minutes for help on multiple occasions, with one response taking over an hour.

"It made him feel low on the priority list," inspectors noted.

Resident #6, who has multiple sclerosis and uses a wheelchair, described waiting two hours in the bathroom for staff to help her get dressed after using the toilet. She said she was "partially clothed" sitting on the toilet, and her "legs and butt hurt" from the prolonged wait.

She told inspectors that over a recent weekend, staff came to help her onto the toilet, then left saying they'd be back in a few minutes. When they didn't return, she turned her call light on again. Someone came back saying they needed another person and would return again.

"Resident #6 stated she waited for 2 hours for someone to come back to assist her off the toilet, with toileting hygiene, and lower body dressing," the inspection report states.

Call light records showed Resident #6 waited longer than 20 minutes for help 12 times in one month, including waits of 47 minutes and 43 minutes.

Resident #24, admitted in February, became incontinent twice due to insufficient staffing. She said staff might answer her call light in five minutes but then took 40 minutes to return with help.

"She reported she felt like a baby when she became incontinent," inspectors wrote.

The resident asked for Tylenol at 1:15 AM one night and didn't receive it until 7:30 AM. She described two staff members covering three hallways as inadequate.

Her call light records showed 19 instances of waits longer than 15 minutes in three weeks, including one wait of 90 minutes.

Resident #13 told inspectors he waited up to 30 minutes for call light responses and "pooped his pants" while waiting for help. He used his phone to time the responses and said the delays made him feel embarrassed.

Call light records showed Resident #13 waited longer than 15 minutes for help 32 times in one month, with waits ranging from 20 minutes to over an hour.

A certified nursing assistant confirmed Resident #13 "had times when he requested to go to the bathroom, but the staff were busy and not available to take him" and experienced incontinence while waiting.

The administrator said she expected staff to answer call lights within 15 minutes.

In another incident, a certified nursing assistant performed a medical procedure she wasn't trained to do when an agency nurse said she didn't know how to flush a resident's catheter with antibiotic solution.

Resident #6 has a suprapubic catheter that requires daily flushing with gentamicin, an antibiotic solution, to prevent infections. The resident told inspectors that on a Saturday night, an agency nurse said she didn't know how to perform the flush.

The CNA performed the procedure with the resident's guidance, even though she knew it was outside her scope of practice. She told inspectors she left a note for the director of nursing about what happened.

But the director of nursing said she received no note and knew nothing about the incident. She said a CNA doesn't have training to perform such care and that Staff E knew she shouldn't have done it.

The facility also failed to monitor antibiotic use properly. The infection preventionist used a color-coded map to track infections but couldn't provide evidence of when antibiotics began, monitoring of lab data, or evaluation of treated infections.

At the time of inspection, the facility had residents on antibiotics for urinary tract infections and MRSA, but lacked proper documentation of the antibiotic stewardship program required by federal regulations.

These problems represent ongoing failures at Southfield Wellness Community. Federal inspectors found the facility had been cited for the same seven types of violations repeatedly over the past year, including insufficient nursing staff, quality of care issues, and problems with their improvement program.

The administrator acknowledged the repeated violations and said the facility was working on "culture change" and building an effective nursing team. She said change "didn't happen overnight" and that several administrative nurses were no longer at the facility.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Southfield Wellness Community from 2025-03-03 including all violations, facility responses, and corrective action plans.

Additional Resources

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