NHC Healthcare, Lewisburg

In the surveyor’s words

From the most serious findings on record at NHC Healthcare, Lewisburg, in the surveyor’s own words.

• Immediate jeopardy, patternF580Mar 4, 2023

  Based on facility policy review, facility protocol review, medical record review and interview, the facility failed to notify the Medical Doctor (MD)/Nurse Practitioner (NP) for 4 of 4 insulin dependent residents (Resident #11, Resident #13, Resident #22, and Resident #27) reviewed for hyperglycemia. Nursing staff failed to notify the MD/NP for blood sugar levels equal to or greater than 400 mg (milligram)/dL (deciliter). Failure to report blood sugar levels equal to or greater than 400 mg/dL could cause acute/chronic conditions which resulted in organ failure, coma, and/or death, which placed the residents in Immediate Jeopardy IJ (a situation in which the providers non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm,… […]

• Immediate jeopardy, patternF726Mar 4, 2023

  Based on facility policy review, facility document review, employee file review, medical record review, and interview, the facility failed to ensure that licensed nurses were competent and proficient to provide care consistent with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for transfer to the emergency department. Nursing staff failed to recognize and properly assess Resident #2's change in condition. Failure to recognize and properly assess Resident #2's change in condition resulted in continued deterioration of her condition, and she was transferred via emergency transport to the local emergency department where she expired. […]

• Immediate jeopardy, patternF835Mar 4, 2023

  Based on job description review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the residents. Administration failed to provide oversight to ensure nursing staff notified the Medical Doctor (MD)/Nurse Practitioner (NP) for intervention of blood sugar levels equal to or greater than 400 mg/dL for 4 of 4 insulin dependent residents (Resident #11, Resident #13, Resident #22, and Resident #27) reviewed. Administration failed to ensure competent nursing staff provided care consistent with professional standards of practice for 1 resident (Resident #2) when nursing staff failed to appropriately assess Resident #2's change in condition. […]

• Immediate jeopardy, patternF867Mar 4, 2023

  Based on facility policy review, Quality Assurance and Performance Improvement (QAPI) meeting documentation review, medical record review, and interview, the QAPI committee failed to ensure an effective QAPI program that identified opportunities for improvement. The QAPI Committee failed to provide oversight to ensure nursing staff notified the Medical Doctor (MD)/Nurse Practitioner (NP) for intervention of blood sugar levels equal to or greater than 400 mg/dL for 4 residents (Resident #11, Resident #13, Resident #22, and Resident #27). […]

• Immediate jeopardy, isolatedF689Mar 14, 2024

  Based on facility policy review, Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, facility investigation review, facility document review, and interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control and provide supervision for 1 of 3 (Resident #1) sampled residents reviewed for accidents. On 12/27/2023, Resident #1 had an unwitnessed fall from an elevated bed and sustained bilateral lower extremity compound fractures of the tibia and fibula and a comminuted fracture of the left patella. Resident #1 was transferred via air ambulance (helicopter) to a level 1 trauma center for emergent care. […]