BRIAN CENTER HEALTH AND REHAB/HENDERSONVILLE
LOCATED: 1870 PISGAH DRIVE, HENDERSONVILLE, NC 28791
BRIAN CENTER HEALTH AND REHAB/HENDERSONVILLE was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews and staff interviews the facility failed to provide supervision for a resident who fell from bed and fractured his right hip for 1 of 3 sampled residents for accidents. (Resident #192).
During an interview on [DATE] at 2:53 PM with Resident #192’s roommate who was cognitively intact for daily decision making he explained he remembered the night Resident #192 rolled out of bed onto the floor. He stated prior to the fall a Nurse Aide (NA) was in the room around 11:00 PM on [DATE] and provided care to Resident #192. He further stated no staff came back into the room after that until Resident #192 rolled out of bed and hit the over bed table and it bumped into his bed and he looked and saw Resident #192 on the floor. He explained he pushed the call light but nobody came to the room so he sent a text on his phone to a family member to call the nurse’s station to tell them to check on Resident #192. He confirmed he sent the text message at 4:28 AM and a nurse came in the room at 4:36 AM. He explained the nurse called for assistance and another nurse and 2 Nurse Aides (NAs) came into the room and picked Resident #192 up off the floor and put him in the bed. He stated he asked Resident #192 what had happened and he said he needed to go to the bathroom and fell.
During a phone interview on [DATE] at 3:50 PM with a family member of Resident #192 she stated Resident #192 had hip surgery after he went to the hospital and was discharged to another facility but had recently expired because he never recovered and could not walk. She further stated the roommate had reported to her that NAs had not checked on Resident #192 during the night and he had to text his family to call the nurses station because they did not answer the call light.
During an interview on [DATE] at 10:23 AM with Certified Medication Aide #2 she explained she arrived at the facility at 3:00 AM on [DATE]. She explained at night there was 1 Nurse Aide on the hall where Resident #192 lived to provide care to residents. She stated NAs were supposed to do rounds and check on residents every 2 hours or more often as needed. She further stated she did not go into Resident #192’s room on [DATE].
During an interview on [DATE] at 10:43 AM with Nurse #4 who identified herself as a Unit Manager of the unit where Resident #129 lived explained when she arrived at the facility in the morning on [DATE] after Resident #192’s fall Nurse #5 who was assigned to Resident #192’s care on the night shift stated he was found on the floor in his room around 4:30 AM. She stated Nurse #5 also reported she had assessed Resident #192 and she didn’t think he was injured.
During an interview on [DATE] at 2:22 PM with Nurse #5 who was assigned to care for Resident #192 during the night shift on [DATE], she stated she was going down the hall to take a resident a snack around 4:30 AM and then she looked in on Resident #192 and he was lying in the floor next to his bed. She stated she had not been in Resident #192’s room since the beginning of her shift at 11:00 PM. She further stated she assessed Resident #192 while he was in the floor and she didn’t see any obvious injury so she called for NAs to help her put him back in bed. She explained NAs were supposed to do rounds and check on resident’s every 2 hours or more often as needed but no one had checked on Resident #192 after 11:00 PM that she was aware of.
During an interview on [DATE] at 3:28 PM with the Area Staff Development Manager she explained she was the former Director of Nursing (DON) in the facility when Resident #192 fell on [DATE]. She stated when she got to the facility staff told her Resident #192 had fallen. She stated she started an investigation but did not interview Resident #192 because he was sent to the hospital. She stated she got a statement from the NA who was assigned to Resident #192 during the night shift and was told she assisted Resident #192 with care at 11:15 PM and did not go back in his room after that. She confirmed the NA no longer worked at the facility and attempts to contact her by phone were unsuccessful. She stated it was her expectation that staff should make rounds and check on residents every 2 hours or more often as needed.
Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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