Autumn Care of Waynesville

In the surveyor’s words

From the most serious findings on record at Autumn Care of Waynesville, in the surveyor’s own words.

• Immediate jeopardy, patternF684May 9, 2024

  Based on observations, record review and Resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews nursing staff failed to identify the seriousness of a change in condition for a resident with a diagnosis of insulin dependent diabetes and provide thorough ongoing monitoring and comprehensive assessments. On [DATE] at 2:30 PM Nurse #2 reported to Nurse #1 Resident #280 was sleepy all day. Nurse #1 did not assess Resident #280 until 5:00 PM and observed the resident was only responsive to painful stimuli and obtained a set of vital signs but did not check her blood sugar. The on-call provider was contacted, and Nurse #1 was instructed to transfer Resident #280 to the emergency room . […]

• Immediate jeopardy, patternF726May 9, 2024

  Based on record review, facility staff and Medical Director (MD) interviews, the facility failed to ensure that facility staff (Nurse #1 and Paramedic #1) had completed Skills Competency's and required floor/unit orientation days with a preceptor prior to taking a resident assignment independently. On [DATE] at 2:30 pm, Nurse #2 informed Nurse #1 that Resident #280 had been excessively sleepy during her shift. Nurse #1 failed to assess Resident #280 until 5:00 pm, at which time Resident #280 was only responsive to painful stimuli. Nurse #1 was instructed at 6:30 pm to transfer Resident #280 to the hospital for evaluation and treatment. […]

• Immediate jeopardy, isolatedF600May 9, 2024

  Based on record reviews, staff, and Medical Director (MD) interviews the facility failed to protect a Resident's right to be free from neglect when Resident # 280 experienced a medical emergency and emergency medical services (EMS) were not provided. The resident was only responsive to painful stimuli on [DATE] around 5:00 PM and 911 was not initiated until 8:10 PM. Resident #280 was transferred to the hospital and diagnosed with metabolic encephalopathy (a problem in the brain caused by a chemical imbalance) due to urinary tract infection (UTI) and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. On [DATE] Resident #280 was discharged to hospice care for comfort care. On [DATE] Resident #280 expired. This occurred for 1 of 3 residents reviewed for neglect. […]

• Actual harm, isolatedF686May 9, 2024

  Based on record review, family and staff interviews, the facility failed to prevent a pressure injury for a resident wearing a hinged knee brace. Resident #280 sustained an open pressure injury that became infected, had developed dead tissue, and wound treatments had not been completed. The deficient practice was identified for 1 of 2 residents (Resident #280) reviewed for pressure ulcers. The findings included: Review of the Orthopedic Progress note dated 1/5/2024 (prior to admission to the facility) revealed Resident #280 was treated nonoperatively for a right proximal tibia (bone in the lower leg) fracture and required a hinged knee brace locked in extension (leg straight) for her right leg. […]

• Actual harm, isolatedF689May 9, 2024

  Based on record reviews, family member, staff, resident, and lift company representative interviews the facility failed to prevent injury when transferring a resident (Resident #280) from a wheelchair to the bed causing a laceration to the resident's left lower leg which required a transfer to the emergency department and treatment of the laceration with sutures. The facility failed to provide a safe transfer when they did not use a mechanical sit-to-stand lift in accordance with manufacturer instructions to transfer a resident (Resident #60). This deficient practice occurred for 2 of 3 residents (Resident #280 and Resident #60) reviewed for accidents and hazards. The findings included: 1. […]