Resident #13 required tube feeding because she couldn't swallow safely, yet she routinely tampered with her medical equipment and consumed dangerous items. The facility's Director of Nursing knew the resident "would go through the trash, ask other residents for drinks and would disconnect her tube feeding at times." She also knew the resident "would chew food items and spit them out."
Despite being aware of these life-threatening behaviors, staff only "redirected" the resident when they observed her actions. Nobody assessed whether she was capable of safely managing her own tube feeding. Nobody informed the physician.
The Activities Director gave food as bingo prizes to a resident who couldn't swallow safely. The Director of Nursing said she wasn't aware this was happening.
The facility's Nurse Practitioner witnessed the dangerous behaviors firsthand. She had seen Resident #13 "in the trash" and watched her steal medical supplies including gauze, gloves and briefs from nurses' carts. The Nurse Practitioner had to convince the resident to return the stolen items.
The Nurse Practitioner knew Resident #13 was "self-administering her tube feeding and putting sports drink in her g-tube." She knew the resident had experienced low blood sugar episodes "from not receiving her tube feedings because she disconnected herself from the pump."
Yet she never discussed these incidents with the physician. Her reasoning: "Resident #13 was going to do what she was going to do and that she did not have time to call the physician every time Resident #13 had behaviors."
The Registered Dietitian, responsible for ensuring adequate nutrition, was never informed that the resident was disconnecting her tube feedings. Without this information, the dietitian couldn't adjust the feeding schedule to compensate for missed nutrition.
When inspectors interviewed the Medical Director on September 18, he was shocked to learn what had been happening. He stated that Resident #13 self-administering her tube feedings "put Resident #13 at risk of serious injury/harm from aspiration, overfeeding, and infection."
The Medical Director had never been told about the resident digging in trash or chewing and spitting out food. Had he known, he said he would have recommended "100% supervision during Resident #13's tube feedings."
The disconnect between what staff observed and what they reported to medical professionals created a dangerous gap in care. The Director of Nursing acknowledged "the dangers of all these behaviors" but failed to ensure proper medical oversight.
The Nurse Practitioner had tried talking to Resident #13 about the risks. The resident "voiced compliance but then would continue the behaviors." Rather than escalating to the physician for a comprehensive safety plan, staff continued their ineffective approach of occasional redirection.
Federal inspectors found the facility's response inadequate for someone whose behaviors posed immediate threats to her safety. Tube feeding requires precise medical management, particularly for residents who cannot swallow safely. Disconnecting the feeding equipment could lead to aspiration pneumonia if the resident attempted to eat or drink. Sports drinks poured directly into a feeding tube could cause dangerous blood sugar spikes.
The inspection revealed a pattern of staff awareness without appropriate action. Multiple employees knew about the dangerous behaviors. None ensured the medical team had the information needed to protect the resident.
The facility's approach of education and redirection might work for minor behavioral issues. For a resident whose actions could cause choking, infection, or nutritional crisis, it represented a fundamental failure of medical supervision.
Resident #13's case illustrates how nursing homes can fail residents with complex medical needs. The facility had the knowledge to recognize dangerous behaviors but lacked the systems to ensure appropriate medical response. Staff watched a resident put herself at risk daily and never implemented the supervision her condition required.
The Medical Director's statement that he would have recommended constant supervision during tube feedings suggests a solution was available. The facility simply failed to connect the dots between what staff observed and what medical professionals needed to know to keep the resident safe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mount Olive Center from 2025-10-01 including all violations, facility responses, and corrective action plans.