BURLINGTON, NC- ALAMANCE HEALTH CARE CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey. 

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on review of photographs of facility resident records and anonymous caller interview, the facility failed to protect the private health information for 3 of 4 sampled residents(Resident #119, #128 and #335) by staff photographing confidential medical information. In addition, based on record review and interview of staff, the facility failed to document the resident’s insulin administration on the medication administration record for 9/29/23 at bedtime (Resident #135) for 1 of 3 residents reviewed for residents with diabetes.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on observations, resident and staff interviews and record review, the facility’s quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 9/19/22, and 5/27/21 and for the complaint investigation surveys dated 12/13/21, 3/31/22, 1/17/23 and 7/6/23 in order to achieve and sustain compliance. These were for recited deficiencies on a recertification survey on 11/2/23. The deficiencies were in the following areas: quality of care, residents are free of significant med error, label/ store drugs and biologicals, food procurement, store/prepare/serve – sanitary and resident records- identifiable information. The continued failure during federal surveys of record showed a pattern of the facility’s inability to sustain an effective quality assurance program.

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Based on staff interviews and record review, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in physical or mental status was identified for 1 of 1 resident with a PASRR Level II determination reviewed for PASRR (Resident #11).

Ensure that residents are free from significant medication errors.

Based on record review, staff, Nurse Practitioner (NP) and Medical Director’s interviews, the facility failed to prevent a significant medication error by failing to administer prescribed extra dose of diuretic medication to a resident resulting in two doses of medication being missed for 1 of 1 resident (Resident #128) reviewed for medication errors.