Resident C was discovered in medical distress at 12:39 p.m. on July 22 at Brookside Care Strategies. A nurse documented that the resident had a high heart rate and elevated blood pressure. When staff encouraged her to take medication and drink fluids, she verbally refused and swatted at the cup containing her medicine.
The resident's condition continued deteriorating.
By 2:57 p.m., nearly two and a half hours later, she was excessively sweating with a high heart rate, elevated blood pressure, and rapid breathing. She continued refusing medications and fluids. Only then did staff contact the nurse practitioner, who ordered an emergency room transfer.
The family representative was informed of the hospital transfer but had not been notified during the hours when the resident's condition was declining.
The infection preventionist told inspectors that Resident C was "a very private person" who typically said hello during daily rounds. On the morning of July 22, the resident did not greet her and was not acting normally. The infection preventionist noticed the resident was cold, restless, and sweaty.
She informed the director of nursing, who attempted to get the resident to drink fluids and take medication. The resident adamantly refused.
Around 2 p.m., a nursing assistant approached the infection preventionist and reported that the resident remained altered, with a high heart rate and increased restlessness. The infection preventionist called the nurse practitioner, who ordered the emergency room transfer.
The director of nursing confirmed that Resident C frequently refused medications and was "a very private person." On July 22, staff approached her about the resident's altered state and elevated blood pressure. When she tried to give the resident blood pressure medication, the resident verbally refused and swatted at the medicine cup.
Later that day, the infection preventionist told her the resident remained altered and was being sent to the hospital.
A licensed practical nurse told inspectors that when a change of condition occurred, staff would assess the resident first, then contact the provider and family depending on the resident's condition.
The director of nursing acknowledged that when a change of condition was identified, staff were supposed to complete an electronic interaction form that included notification of family or the resident representative. She confirmed that nursing staff were expected to contact family and resident representatives when a change of condition was identified and document this contact in a progress note.
No such documentation appeared in the resident's record for the hours between 12:39 p.m. and 2:57 p.m. on July 22.
Resident C's medical record showed diagnoses of paranoid schizophrenia, hypertension, and acid reflux. A quarterly assessment from May indicated she was mildly cognitively impaired.
The facility's own policy, provided during the inspection, states that staff "shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition." The policy specifically requires notification when there is "a significant change in the resident's physical, mental, or psychosocial status" and when "it is necessary to transfer the resident to a hospital."
Inspectors found that staff failed to follow this policy during the critical hours when Resident C's condition was deteriorating on July 22.
The violation occurred despite multiple staff members recognizing that the resident was not acting at her baseline and was experiencing medical distress that ultimately required emergency hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookside Care Strategies from 2025-08-22 including all violations, facility responses, and corrective action plans.