PruittHealth-Neuse

In the surveyor’s words

From the most serious findings on record at PruittHealth-Neuse, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 19, 2024

  Based on observation, record reviews and family, staff, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to provide care in a safe manner for 1 of 5 residents (Resident #1) reviewed for supervision to prevent accidents. Resident #1 was diagnosed with cerebellar ataxia (a condition that causes poor muscle control that causes clumsy movements), and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and was dependent on staff for assistance with care. […]

• Immediate jeopardy, isolatedF760Oct 4, 2021

  Based on record review, residents, family, facility staff, [CONDITION(S)] staff and physician interviews, the facility failed to prevent a significant medication error by administering insulin to the wrong resident for 1 of 2 residents (Resident #1). Resident #1 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate jeopardy began on 9/03/21 when the facility failed to prevent a significant medication error by administering insulin to the wrong resident for 1 of 2 residents (Resident #1). Resident #1 was sent to the [CONDITION(S)] center and they sent him to the hospital for [CONDITION(S)]. The immediate jeopardy was removed on 9/30/21 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. […]

• Immediate jeopardy, isolatedF835Oct 4, 2021

  Based on record review and staff interviews, the facility's administration failed to act on an allegation of a significant medication error, failed to determine the validity of the significant medication error allegation, and failed to identify the need to prevent further medication errors for 1 of 2 residents (Resident #1). Immediate jeopardy began on 9/03/21 when the facility failed to determine the validity of the significant medication error allegation which occurred on 9/03/21 and did not identify the need for preventative measures. The immediate jeopardy was removed on 9/30/21 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. […]

• Actual harm, isolatedF689Aug 4, 2026

  Based on staff, and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when the resident fell from the bed during incontinence care, reported left hip pain at a level of 10 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. The resident required evaluation at the emergency department where she was diagnosed with a closed left hip fracture (the upper part of the left thigh bone was broken, but the bone did not break through the skin). This deficient practice affected 1 of 3 residents (Resident #1) reviewed for accidents.Findings included: Resident #1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF760Sep 11, 2024

  Based on record review, and staff, resident, family member, Pharmacist, Psychiatric Nurse Practitioner (NP), and Nurse Practitioner (NP) interviews the facility failed to administer prescribed medications for 1 of 1 resident (Resident # 45) reviewed for significant medication errors. Resident #45 was not administered 10 consecutive doses of lorazepam (anti-anxiety medication) during the time period of 7/29/24 through 8/01/24 when the order was erroneously discontinued on the Medication Administration Record (MAR) by the Director of Nursing (DON) which caused Resident #45 to experience increased anxiety. Resident #45 was assessed by the NP on 8/01/24 due to severe anxiety and noted the resident was crying and asking for his medication. […]