Nursing Home News — Page 578

## Critical Delay in Emergency Care The violation occurred when a resident reported severe hip pain following a fall on November 17, 2024.

This classification requires facilities to implement immediate corrective measures to protect resident safety.

Twenty-two minutes later, they found him walking in a field approximately two blocks from the facility.

The incident prompted immediate corrective actions and a comprehensive review of medication administration protocols.

The resident, who has a spinal cord injury at the thoracic level affecting T2-T6 vertebrae, was in his motorized wheelchair when the incident occurred.

The resident was found unresponsive in his wheelchair at 4:30 AM with blood sugar levels exceeding 500 mg/dl - more than five times the normal range.

Staff also attempted to administer blood pressure medications when the resident's pressure was dangerously low at 97/41.

The resident's face appeared "reddish purple" with only a weak pulse detected and no visible breathing patterns observed.

The facility's response proved inadequate at multiple levels.

"The food at the facility was terrible as it was sometimes cold when it arrives," Resident 173 told inspectors.

Despite having a comprehensive behavior care plan in place, staff failed to implement critical interventions that could have prevented the attack.

Despite these clear medical directives, facility records show that insulin was discontinued on the day of admission.