Deficiencies put “all residents” at risk

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State leaders on North Carolina’s Joint Legislative Oversight Committee on Health and Human Services heard a report on Tuesday outlining alleged shortcomings and egregious errors at the Pine Ridge Health and Rehabilitation Center in Thomasville. non-compliance with regulations,” said deputy director of the state’s Division of Health Services Regulation, Emery Milliken. Those calls, she said, prompted a wellness check by local law enforcement. fed or received food from residents who had not received treatment for incontinence, he had discovered a resident lying in her own vomit. and other staff. It also included, she said, a review of 911 calls and a review of resident care plans. The Division of Health Services Regulation is the regulatory agency. federally designated investigation, she said. were entrusted to the care of a licensed practical nurse and two practical nurses as of 2 p.m. on January 16. She said many residents are completely dependent on staff for meals, medication, bathroom use and a wide range of other needs. Milliken said there are usually 13 to 15 staff on hand to care for that many patients. The incident happened on January 16 and 17. Milliken said DHSR’s investigation showed many scheduled staff either did not come to work or left early when weather conditions worsened during a snowstorm. “The end result created a situation where there were so few staff present at the facility that residents of the facility called 911 for help,” she said. A caller, Milliken said, told 911 operators she hadn’t seen staff in hours and couldn’t reach staff members, and was wet and hungry. Milliken said the facility had a “sleep allowance” to pay staff to sleep at the facility during inclement weather, but staff were unaware of the policy. “Our investigators, when on site, found that although Pine Ridge had an emergency preparedness plan – a plan that actually included a specific section for winter emergency procedures – the plan did not ever been activated for this incident,” Milliken said. Milliken said the Health Services Regulatory Division investigation determined the facility had 13 practice areas, with eight deficient practices serious enough to be designated as at the ‘immediate danger level.’ Milliken called immediate danger designations the ‘most severe type of impairment.’ She said the severity of these eight areas of non-compliance put the health and safety of residents at risk serious injury, impairment or death The facility was required to submit a remediation plan The Health Services Regulation Division will review the improvements and determine if the shortcomings have been corrected. Milliken said the most serious issues had been improved but the facility was still in non-compliance on Tuesday. Milliken said it may take time to make all the necessary improvements to get back into compliance with the state. The facility said the fixes will be in place by March 23. Pine Ridge can appeal the state’s findings. Milliken said a copy of the Division of Health Services Regulation report was requested by local police departments and the state Bureau of Investigation.

State leaders on North Carolina’s Joint Legislative Oversight Committee on Health and Human Services heard a report on Tuesday outlining alleged shortcomings and egregious errors at the Pine Ridge Health and Rehabilitation Center in Thomasville.

“All residents were at risk of a serious negative outcome due to non-compliance with regulations,” said deputy director of the state’s Division of Health Services Regulation Emery Milliken.

Milliken presented elected officials with the 159-page report Tuesday morning, saying residents called 911 after being unable to reach staff as a snowstorm worsened. Those calls, she said, prompted a wellness check by local law enforcement.

The report states that a paramedic who responded that night is quoted in the report as saying, “He felt residents had been neglected due to sightings of residents who had not been fed or received food, residents who had not received incontinence care, he had discovered a resident who was lying in her own vomit.

The report, according to Milliken, included interviews with 89 people, including residents, law enforcement, first responders and other personnel. It also included, she said, a review of 911 calls and a review of residents’ care plans.

The Division of Health Services Regulation is the federally designated state investigative agency, she said.

The investigation revealed that 98 residents were in the care of a licensed practical nurse and two practical nurses from 2 p.m. on January 16. She said many residents are completely dependent on staff for meals, medications, bathroom use and a wide variety of other needs. Milliken said there are usually 13 to 15 staff on hand to care for that many patients.

The incident happened on January 16 and 17. Milliken said DHSR’s investigation showed many scheduled staff either did not come to work or left early when weather conditions worsened during a snowstorm.

“The end result created a situation where there were so few staff present at the facility that residents of the facility called 911 for help,” she said.

A caller, Milliken said, told 911 operators she hadn’t seen staff in hours and couldn’t reach staff members, and was wet and hungry. Milliken said the facility had a “sleeping allowance” to pay staff to sleep at the facility in inclement weather, but staff were unaware of a policy.

“Our investigators, while on site, discovered that although Pine Ridge had an emergency preparedness plan – a plan that actually included a specific section for winter emergency procedures – the plan was never activated for this incident,” Milliken said. .

Milliken said the Division of Health Services Regulation investigation determined the facility had 13 areas of deficient practice, with eight deficient practices severe enough to be designated as at the “immediate danger level.”

Milliken called immediate danger designations “the most serious type of deficiency.” She said the severity of these eight areas of non-compliance put the health and safety of residents at risk for serious injury, impairment or death.

The establishment was required to submit a remediation plan. The Health Services Regulation Division will review the improvements and determine if deficiencies have been corrected. Milliken said the most serious issues had been improved but the facility was still in non-compliance on Tuesday.

Milliken said it may take time to make all the necessary improvements to get back into compliance with the state. The facility said the fixes will be in place by March 23.

Pine Ridge may appeal the state’s findings.

enforcement

Milliken said a copy of the Division of Health Services Regulation report was requested by local police departments and the state Bureau of Investigation.

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