Elizabeth City Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Elizabeth City Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Nov 22, 2023

  Based on record review, staff interviews, and Medical Director interview the facility failed to notify the physician of administering long-acting insulin to Resident # 1 who had not consumed dinner and had a blood glucose level of 89 mg/dL (milligrams per deciliter). The facility failed to notify the physician after significant changes in condition for Resident #1 which included: obtaining a blood glucose level of 29 mg/dL (a normal blood glucose level range is 70 to 99 mg/dL) requiring the administration of glucagon (a manmade version of a hormone made by the pancreas that raises blood glucose levels); and obtaining a blood glucose level of 27 mg/dL, and the inability to administer glucagon to the Resident during a medical emergency. […]

• Immediate jeopardy, isolatedF684Nov 22, 2023

  Based on record review, staff interviews, Pharmacy Nurse Consultant interview, Pharmacist interview, and Medical Director interview, the facility gave long-acting insulin to Resident #1 who had a blood sugar reading of 89 milligrams/deciliter (mg/dL) and had not eaten the dinner meal; failed to monitor the resident for any signs and symptoms of hypoglycemia (low blood glucose) after insulin administration; failed to monitor and complete ongoing thorough assessments by rechecking a blood glucose level as ordered after a hypoglycemic event requiring the intervention of glucagon (used to treat very low blood glucose); and failed to effectively respond to a medical emergency of hypoglycemia for one (Resident #1) of three residents reviewed for diabetes care. […]

• Immediate jeopardy, isolatedF726Nov 22, 2023

  Based on record review, staff, Pharmacist, Pharmacy Nurse Consultant, and Medical Director interviews the facility failed to demonstrate competency knowing what effective immediate interventions needed to be implemented for treatment of hypoglycemia (low blood glucose) and competency in obtaining life-saving medication from an automated medication dispensing system for one (Resident #1) of one resident reviewed for nursing competency. Emergency Medical Services (EMS) was contacted to take Resident #1 to the emergency roiagnom on [DATE] for hypoglycemia. EMS treated Resident #1 with 1 mg glucagon intermuscular. […]

• Actual harm, isolatedF600Oct 28, 2023

  Based on record review, observation, staff interview, resident interview, physician interview, physician assistant interview, and family interview the facility failed to prevent intentional inappropriate touching for one of three residents reviewed for resident-to-resident abuse. Resident #1 was observed by Resident #3 touching the breasts of Resident #2 under her shirt after the conclusion of a planned activity event with a gathering of the residents. Resident #2 did not have the cognition to express an adverse outcome, inappropriate touching of their breasts would have traumatized a reasonable female person. A family member of Resident #2 confirmed Resident #2 would have been devastated, furious, and mad at being touched inappropriately by a man if she was not cognitively impaired. […]

• Actual harm, isolatedF689Jan 27, 2023

  Based on record review and staff interviews, the facility failed to provide care safely when a resident (Resident #295) was provided with incontinence care. Resident #295 fell from the bed during care and sustained a 2.5-centimeter (cm) laceration to her head with bleeding and she reported pain in her back and head post fall. Resident #295 was sent to the hospital and required 3 staples to close the laceration. This was for 1 of 8 residents reviewed for accidents (Resident #295). Findings included: Resident #295 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's and contractures. […]