The Foley Center At Chestnut Ridge
The Foley Center at Chestnut Ridge in Blowing Rock, NC — inspection on July 3, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to notify a provider when Resident #278 was noted by Medication Aide #1 to have difficulty breathing, had an oxygen saturation of the high 70's/low 80's, and was asking for help. On [DATE], Upon being made aware of allegation of neglect, Administrator completed and submitted initial allegation report to Department of Health and Human Services. On [DATE], all current residents were assessed for change in condition to ensure anyone requiring change in condition received necessary care & services.
On [DATE], the Director of Nursing identified residents that were potentially impacted by this practice by completing head to toe body audits and assessed residents for any acute distress or verbal/nonverbal indicators of neglect with a BIMS 12 or less on all current residents.
The results included: all current residents with BIMS 12 (impaired cognition) or less had no areas of concern identified related to abuse/neglect. On [DATE], all current residents with a BIMS of 13 or above were interviewed by the Administrator and were asked if they had any concerns related to abuse/neglect and if they had any care concerns.
The results included: All current resident with BIMS 13 (intact cognition) or higher denied any allegations of abuse/neglect occurred and identified.
Additionally, on [DATE], the Director of Nursing met with all direct care nurses who were working to initiate an assessment of 100% of current residents.
This audit consisted of review of any residents with any acute change in condition to ensure the provider was notified of the change in condition.
The change in condition included: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed including any change in condition where the resident has difficulty breathing, low oxygen saturations, and new onset cough, congestion with decreased appetite.
This audit was completed on: [DATE].
The audit identified that 2 of 79 residents had an acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed including any change in condition where the resident has difficulty breathing, low oxygen saturations, new onset cough, and congestion with decreased appetite. On [DATE], a corrective action was completed for 2 of 79 residents identified as having a change in condition when the provider was notified of the change in condition and orders for the change in condition were carried out by the direct care staff.
345045
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 345045 B.
Wing 07/03/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Foley Center at Chestnut Ridge 621 Chestnut Ridge Parkway Blowing Rock, NC 28605
F-F684: Based on record review, and staff, Resident Representative (RR), Social Worker (SW), Nurse Practitioner (NP), and Medical Director (MD) interviews Based on record review, and staff, Resident
jeopardy to resident health or facility failed to complete and document on-going thorough assessments for an acute change in condition safety and failed to respond effectively to a medical emergency. On [DATE] at 7:00 pm, Resident #278's Representative requested a chest x-ray, when Nurse #1 observed Resident #278 had a cough, congestion,
breaking up mucous/congestion every 12 hours and nebulizer breathing treatments four times a day were ordered for 7 days for a cough. On [DATE] at 7:00 am, Medication Aide (MA) #1 was told by the off going nurse, Nurse #2, that Resident #278 was not doing well. MA #1 checked Resident #278's oxygen saturation and noted it was in the high 70's/low 80's (normal oxygen saturation is 92 to 100%) and got the Director of Nursing (DON).
The DON advised MA #1 to place Resident #278 on oxygen and continue to monitor oxygen saturation levels. MA #1 continued to report breathing issues and concern about Resident #278 struggling to breathe to the DON throughout the day until Resident #278 was removed from the facility by the RR at 4:47 pm.
The RR took Resident #278 to the Emergency Department where Resident #278 was diagnosed with Influenza A (the flu) Influenzal Bronchitis (inflammation of the airway), had an elevated white blood cell count (which indicated infection), and was given intravenous fluids, steroids (used to decrease inflammation), a breathing treatment, and was admitted to the hospital. Resident #278 was later diagnosed with acute hypoxemic respiratory failure and was placed on comfort measures on [DATE], received inpatient hospice services in the hospital and expired on [DATE].
The certificate of death revealed Resident #278's immediate cause of death was acute hypoxemic respiratory failure, Influenza A, and bacterial pneumonia.
The deficient practice was identified for 1 of 3 residents (Resident #278) reviewed for change in condition.