NC State Veterans Home - Black Mountain

In the surveyor’s words

From the most serious findings on record at NC State Veterans Home - Black Mountain, in the surveyor’s own words.

• Immediate jeopardy, widespreadF725Jul 12, 2023

  Based on record reviews and staff interviews the facility failed to provide adequate staffing to provide care on [DATE]. The evening of [DATE] Nurse #1 worked from 7:33 PM until 11:00 PM and was the only licensed nurse to provide resident care and services for 71 residents in the facility. Nurse #1 did not know where to locate transfer paperwork for Resident #1 and as a result he was not sent to the hospital until hours after the facility was notified of an elevated troponin level (a heart enzyme that can indicate heart damage). Nurse #1 was not aware she was the only nurse in the facility until approximately 8:30 PM when Nurse Aide #1 communicated this to her and informed her a resident on the [NAME] unit had requested an as needed medication. […]

• Immediate jeopardy, isolatedF684Jul 12, 2023

  Based on record review, staff and Nurse Practitioner and Medical Director (MD) interviews the facility failed to send a resident with an elevated troponin (a heart enzyme that can indicate heart damage) to the hospital on 06/26/23, as ordered by the Physician. A troponin level was ordered by the Physician 06/26/23, with results reported back to the facility on [DATE], which noted a troponin level of 6.730 nanograms per milliliter (the reference range is 0.000-0.034 ng/ml). On 06/26/23 at 7:16 PM, the Physician gave orders to send the resident to the hospital, but Emergency Medical Services (EMS) were not notified of the need for resident transport to the hospital until 11:43 PM. The Physician was not notified of the delay in sending the resident to the hospital on 06/26/23. […]

• Immediate jeopardy, isolatedF551Sep 13, 2021

  Based on record review, interviews with resident, staff, the legal guardian (LG) with Department of Social Services (DSS) and the Medical Director, the facility failed to obtain authorization from the LG for Resident #1 to leave the facility, and to discharge out of the facility against medical advice (AMA). Resident #1 left the faciity on two occasions without medications and medical care. He was evaluated at the hospital due to [CONDITION(S)] the first time he left the facility. The second time Resident #1 left the facility he was evaluated at the hospital for complaints of cough and chest pain and a few days later he was taken to the hospital by his LG and admitted due to alcohol consumption and subpar personal hygiene. […]

• Immediate jeopardy, isolatedF624Sep 13, 2021

  Based on record review and staff, resident, Physician and Legal Guardian (LG) interviews the facility failed to make provisions for Resident #1's needs for a safe discharge and did not provide him with prescriptions or medications, assess the accessibility or safety of his discharge destination, determine if he would have access to food and running water, refer him for home health services or contact the Veterans Administration (VA). The day after Resident #1 was discharged Against Medical Advice (AMA) spent a night in the emergency room (ER) due to complaint of cough and chest pain and was diagnosed with pneumonia. He was hungry while in the emergency room and kept requesting food. This occurred for 1 of 3 sampled residents reviewed for safe and orderly discharge. […]

• Actual harm, isolatedF600Sep 5, 2024

  Based on record review, observations, and interviews with staff the facility failed to protect a resident's right to be free from abuse (Resident #33) when a resident (Resident #324) physically pulled him to the floor causing a fall. During a second physical altercation Resident #324 grabbed hold of Resident #33 causing him to fall on his left hip. After the second fall Resident #33 was unable to move his left leg, complained of pain to the leg and hip, and was transferred to the hospital. The hospital x-ray identified an acute left femoral neck fracture (a break of the upper leg bone just below the joint that connects to the hip) with mild varus angulation (a displacement of the bone causing it to tilt inward towards the midline of the body). […]