GOLDEN LIVING CENTER – DARTMOUTH
LOCATED: 300 PROVIDENCE ROAD, CHARLOTTE, NC 28207

GOLDEN LIVING CENTER – DARTMOUTH was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT.

LEVEL OF HARM – ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews, staff and physician interviews the facility failed to assess a resident with a change in condition with increased pain and confusion for 1 of 4 sampled residents with a change in condition. (Resident #12)

A review of an emergency medical transport report dated [DATE] at 10:46AM indicated the emergency medical transport staff arrived to facility to transport Resident #12 to an Infectious Disease Physician appointment. The crew reported the facility reported Resident #12 was at her baseline mental status but the Infectious Disease Physician reported Resident #12 was not at her baseline mental status and he was concerned and wanted her to be transported to the hospital for evaluation. The assessment notes revealed at 10:50 AM Resident #12 was on oxygen at 6 liters per minute and at 10:56 AM her blood pressure was, [DATE], pulse 100 and respirations 18. The report also indicated Resident #12 left the physician’s office by medical transport at 11:04 AM and arrived at the hospital emergency room at 11:07 AM. A review of a laboratory report dated [DATE] for a urinalysis and culture and sensitivity indicated results of rare bacteria and moderate amounts of yeast. A handwritten note on the bottom of the results indicate Resident #12 was currently on Bactrim DS ,[DATE] mg daily by mouth and the Nurse Practitioner was notified on [DATE] at 10:50 AM. A review of a hospital emergency department report dated [DATE] at 11:12 AM indicated Resident #12 was admitted with altered mental status [MEDICAL CONDITION] (a life threatening complication of infection). A review of nurse’s notes dated [DATE] at 11:34 AM documented by the Director of Nursing (DON) indicated a nurse from the Infectious Disease Physician’s office called and reported Resident #12 was sent to the hospital emergency room due to unresponsiveness. During a telephone call on [DATE] at 3:19 PM with a Medical Office Assistant at the Infectious Disease Physician’s office she stated she remembered when Resident #12 came to the office on [DATE]. She explained Resident #12 was barely responsive, was not talking but was mumbling sounds and appeared to be in pain. She stated medics transported her to the office from the facility and she was brought immediately into an exam room when they got there and stated documentation in her chart indicated her vital signs were, [DATE], pulse 64, respirations 26 and temperature was 97.6 degrees F. During an interview on [DATE] 11:40 AM with NA #9 she explained when Resident #12 first came to the facility she was independent but then she began to need more help. She stated during the past 2 days before she went out to the doctor’s appointment on [DATE] they had to feed her and she needed total help. She explained Resident #12 complained of bad pain in her back and she reported it to the nurse.
Continuing: During a telephone interview on [DATE] at 1:14 PM the Infectious Disease Physician stated it was reported to him by one of his physician partners that Resident #12 had died in the hospital on [DATE] at 2:02 AM. He stated her admitting [DIAGNOSES REDACTED]. He explained he had seen Resident #12 about a month ago during a previous hospital admission because she had infected hardware due to back surgery and she was alert at that time. He confirmed he saw Resident #12 when she came to his office on [DATE] and she was minimally awake but was not responsive and was receiving oxygen but her saturation percentage was 88% and her blood pressure was low at, [DATE], pulse 64, respirations 26 and her temperature was 97.6 F. He explained he talked to emergency medical transport and they said when they picked the resident up she was on oxygen at 2 liters per minute but they had to increase her oxygen because her oxygen saturation percentage was in the low to mid 80’s and she was minimally responsive. He stated he took a quick look at Resident #12 and told emergency medical transport personnel to take her to the hospital emergency room. He explained after Resident #12 left the office he had his staff call the facility and they were told Resident #12 was a little confused when she left the facility. He stated he received no notes from the facility and had no indication of what had happened with Resident #12. He stated the last time he saw Resident #12 about a month ago she was alert and awake. He confirmed his office was just down the street from the facility so Resident #12’s transport would have only taken minutes. During an interview on [DATE] at 9:30 AM the facility Medical Director stated he only saw Resident #12 once on [DATE] but his Nurse Practitioner saw her routinely and kept him informed of Resident #12’s condition. He explained Resident #12’s biggest problem was infected hardware in her back but she also had a lot of medical conditions and was getting intravenous antibiotics through a PICC line and was followed by an Infectious Disease Specialist who managed the infected hardware in her back. He stated the Nurse Practitioner had questions about the antibiotics and did not want to make decisions about them on her own so she called the Infectious Disease Physician for his recommendations and he wanted to see Resident #12 at his office on [DATE]. He explained it was his expectation for nursing staff to assess residents who had a change in condition and call the physician. He stated a Physician or Nurse Practitioner was available by phone or pager 24 hours a day and there was no excuse for them not being notified. He further stated he was not aware of Resident #12’s increased confusion and pain and nursing staff should have called them regarding Resident #12’s pain since pain medication had already been given on [DATE] and [MEDICATION NAME] was not indicated for pain. He explained he couldn’t speak to whether Resident #12’s outcome would have been different but he expected staff should have called to discuss pain, medications and assessment of the resident because the chances of recovery were better the sooner he was notified.

Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

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