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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.



Based on record reviews, staff and physician interviews the facility failed to assess a resident with a change in condition with increased pain and confusion for 1 of 4 sampled residents with a change in condition. (Resident #12)

A review of an emergency medical transport report dated [DATE] at 10:46AM indicated the emergency medical transport staff arrived to facility to transport Resident #12 to an Infectious Disease Physician appointment. The crew reported the facility reported Resident #12 was at her baseline mental status but the Infectious Disease Physician reported Resident #12 was not at her baseline mental status and he was concerned and wanted her to be transported to the hospital for evaluation. The assessment notes revealed at 10:50 AM Resident #12 was on oxygen at 6 liters per minute and at 10:56 AM her blood pressure was, [DATE], pulse 100 and respirations 18. The report also indicated Resident #12 left the physician’s office by medical transport at 11:04 AM and arrived at the hospital emergency room at 11:07 AM. A review of a laboratory report dated [DATE] for a urinalysis and culture and sensitivity indicated results of rare bacteria and moderate amounts of yeast. A handwritten note on the bottom of the results indicate Resident #12 was currently on Bactrim DS ,[DATE] mg daily by mouth and the Nurse Practitioner was notified on [DATE] at 10:50 AM. A review of a hospital emergency department report dated [DATE] at 11:12 AM indicated Resident #12 was admitted with altered mental status [MEDICAL CONDITION] (a life threatening complication of infection). A review of nurse’s notes dated [DATE] at 11:34 AM documented by the Director of Nursing (DON) indicated a nurse from the Infectious Disease Physician’s office called and reported Resident #12 was sent to the hospital emergency room due to unresponsiveness. During a telephone call on [DATE] at 3:19 PM with a Medical Office Assistant at the Infectious Disease Physician’s office she stated she remembered when Resident #12 came to the office on [DATE]. She explained Resident #12 was barely responsive, was not talking but was mumbling sounds and appeared to be in pain. She stated medics transported her to the office from the facility and she was brought immediately into an exam room when they got there and stated documentation in her chart indicated her vital signs were, [DATE], pulse 64, respirations 26 and temperature was 97.6 degrees F. During an interview on [DATE] 11:40 AM with NA #9 she explained when Resident #12 first came to the facility she was independent but then she began to need more help. She stated during the past 2 days before she went out to the doctor’s appointment on [DATE] they had to feed her and she needed total help. She explained Resident #12 complained of bad pain in her back and she reported it to the nurse.
Continuing: During a telephone interview on [DATE] at 1:14 PM the Infectious Disease Physician stated it was reported to him by one of his physician partners that Resident #12 had died in the hospital on [DATE] at 2:02 AM. He stated her admitting [DIAGNOSES REDACTED]. He explained he had seen Resident #12 about a month ago during a previous hospital admission because she had infected hardware due to back surgery and she was alert at that time. He confirmed he saw Resident #12 when she came to his office on [DATE] and she was minimally awake but was not responsive and was receiving oxygen but her saturation percentage was 88% and her blood pressure was low at, [DATE], pulse 64, respirations 26 and her temperature was 97.6 F. He explained he talked to emergency medical transport and they said when they picked the resident up she was on oxygen at 2 liters per minute but they had to increase her oxygen because her oxygen saturation percentage was in the low to mid 80’s and she was minimally responsive. He stated he took a quick look at Resident #12 and told emergency medical transport personnel to take her to the hospital emergency room. He explained after Resident #12 left the office he had his staff call the facility and they were told Resident #12 was a little confused when she left the facility. He stated he received no notes from the facility and had no indication of what had happened with Resident #12. He stated the last time he saw Resident #12 about a month ago she was alert and awake. He confirmed his office was just down the street from the facility so Resident #12’s transport would have only taken minutes. During an interview on [DATE] at 9:30 AM the facility Medical Director stated he only saw Resident #12 once on [DATE] but his Nurse Practitioner saw her routinely and kept him informed of Resident #12’s condition. He explained Resident #12’s biggest problem was infected hardware in her back but she also had a lot of medical conditions and was getting intravenous antibiotics through a PICC line and was followed by an Infectious Disease Specialist who managed the infected hardware in her back. He stated the Nurse Practitioner had questions about the antibiotics and did not want to make decisions about them on her own so she called the Infectious Disease Physician for his recommendations and he wanted to see Resident #12 at his office on [DATE]. He explained it was his expectation for nursing staff to assess residents who had a change in condition and call the physician. He stated a Physician or Nurse Practitioner was available by phone or pager 24 hours a day and there was no excuse for them not being notified. He further stated he was not aware of Resident #12’s increased confusion and pain and nursing staff should have called them regarding Resident #12’s pain since pain medication had already been given on [DATE] and [MEDICATION NAME] was not indicated for pain. He explained he couldn’t speak to whether Resident #12’s outcome would have been different but he expected staff should have called to discuss pain, medications and assessment of the resident because the chances of recovery were better the sooner he was notified.

Personal Note from NHAA 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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  1. Vivien Nguyen says:

    Dear Sirs/Madam
    I was crying a lot after reading this & made me miss my Dad so much as he was at LIBERTY NURSING & REHABILITATION CENTER OF MECKLENBURG COUNTY, address at: 3700 SHAMROCK DRIVE,CHARLOTTE, N.C 28215.
    I treated all nurses even office officers with Fruit-Food even tip money & I paid every month for my dad private room since 2009 until 2011 at every time I come to visit my dad 2-3 time a week, because I want they good care my Dad but my Dad alway complain with me that they beat my Dad, They let my Dad fall down from the wheel chair when they give bath to my Dad. I saw the bruise in some places on his body, I am sure you knew what nurses answer when I ask them, they all said NO,
    but I still treat them nice with fruit-Food & money every time I come…
    in 1 day I came and saw my Dad look so bad,he couldn’t breath and he throw up a lot I must required the nursing home to send my Dad to hospital and my dad must stay at ICU immediately because in his lung full of food. the doctor show me how much food & water in his lung which DR sucked out from his lung…almost a gallon & my Dad painful ask me let him die better then keep sucking food from his lung like that…He got INFECTION Seriously after that for almost 3 weeks I stay with him 24/7. I still have picture how bad he was with many Supporting Equipment he must cary on his face & on his body. You can imaging how I was trying to safe his life…I beg the Doctors, the nurse safe my Dad life…During that tim the nursing home never give me a call to ask how is my Dad but ask me money to pay for the room, this officer alway receive from me many many gifts …
    I waste too much money-Food-Fruit to those nurses / officers and for private room in 2 years.
    I have wrote complain to health care department of county but no use & of course the nursing home will not accept what they did to my Dad. Even at PRESBYTERIAL hospital go report, BUT I STILL CAN NOT DO ANYTHING, My father health is weaker what is the use for me to fight with them? I better take care my Dad better…when I realize that NO ONE CAN SEE THE REAL LIFE IN THE NURSING HOME
    More over I knew 1 old lady also long term care staying at there death in closet in few days but no one know, this case went to the court and the judge told me to confirm what I heart from people staying at that nursing home. In that time I went to court to have my Dad personal record so I can summit to have new place for him…
    Not only 1 case but some more case which I knew from some the relative of the resident in Liberty Nursing home, the OLD PEOPLE DIED because THE LIBERTY NURSING HOME DIDN’T CARE TO THEM. Just like my Dad case : how they can let the food go inside my Dad lung and NO DOCTOR OR NURSES pay attention when he hard to breath or throw up? If I didn’t go there that day then how will be happen to my Dad?
    I KEEP just only believe that I treated all nurses & officer so well as no one else did like me, they will not did bad thing to my Dad, But I was so wrong & made mistake on my Dad life…
    I often visit some other rooms to share to talk to them because they are so lonely no visitors like I do to my Dad, They are so happy when I bring for them some fruit, They also told me how they got treated from nursing home, BUT they couldn’t say anything because they will get worse treated if they complain….
    My Dad already pass way at OCT 2012 but I feel so badly guilty that I brought my Dad to death place to make his life shorter and I am murder my own dad.
    Just because I have to work also traveling all the time for my work and many people advice me to bring my dad to nursing home to have better care but actually I am the one kill him.
    He was in good condition, he can walk without stick, he can eat by himself with hard food like meat without any problem BUT when he come to nursing home only few month later (Not yet 6 months) his health went down so badly & so Quickly
    I wish what I writing in here can touch to all department who care for the OLD PEOPLE will not suffering with all those NURSING HOME, actually the place ABUSE the OLD PEOPLE but not CARE for the OLD PEOPLE…All they NEEDED IS JUST MONEY FROM MEDICARE & MEDICAID from GOVERNMENT ONLY. I saw all of them,
    Because after my Dad out of the ICU, I changed him to another NURSING HOME but only 1 night I have to change him to Another nursing home again and he left me in after almost 1 year…
    You see I am so regret and feel so much GUITY that i made my Dad die while he was healthy. Do you know I didn’t see him for 28 years, because he was in WAR PRISON in VIETNAM After communist Government took over on APR 1975,because my Dad working at USA INTELLIGENT Department & he was in prison for 13 years until President BILL CLINTON negotiate with VN GOV release him to go to USA and he live in US for 15 years while I was in Thailand because I also have to run away from COMMUNIST GOV. They call my family is WAR CRIMINAL, they took my house,they don’t allow to work or even go to school and many more…
    That why you can see why thousand people must run away from VN by boat even they knew that might die in the sea or in jungle but they still have to play with their life to run away from COMMUNIST GOV…
    Again Sincerely from bottom of my heart I wish you can do some thing to give the OLD PEOPLE MORE CARE for their OLD TIME, As we are also going there because we all will getting old…
    I really can not understand why all nurses treating old people like that? they think will never old? how they will feel when some one else will treat them the same what they did to the OLD PEOPLE now?
    PLEASE, Take a little of my few words to pay attention more to the OLD,they not deserve to be treated so bad and painful like that.
    I am so much appreciated your time to read my comment but this is just only sharing with you with my guilty feeling about my Dad and this feeling will follow me until I die because I can not forgive to myself to bring my Dad to death place like this
    I also hope that my english is good enough for you can understand what is come from my heart…
    Sincerely from my heart to you my thankful and wishing you all with all the best in healthy and living as you wish
    Vivien Nguyen

    • Terry Hosch says:

      I’m in tears.. So sorry for your dad, you and family.. My mom passed away in 2010. She was at Liberty … My husband and I was there as much as we could every day and night . It was a blessing we could. She was in private room,also. I had run in once with something about them not seeing and helping her eat, but they got better, we would try to make it twice day . I would come different times and talk to them. The Lord took her home . I think she had infection. But doctors had given her about 6 months to live she had spot on lung and base of brain ..I miss her every day …..

      • Vivien Nguyen says:

        I’m so much appreciate for your sharing about my Dad. At the beginning I already doubt with what Doctor in Liberty said after they did checking on my Dad. But I couldn’t say anything just because I respect doctor in Liberty, even when my Dad come back nursing home from hospital (Presbyterian down town) after 1st stroke. I can read English, I can understand when Doctor in hospital told me what to do to care to my dad..&
        I have told to Nurses and with hospital description /Instructions…But they didn’t follow because I can read the medicine name or on the report book from nurse, as I always giving them tip money/food that why they can tell me or show me what I want to see.
        They are heartless and they all will have to pay for what they done to my Dad, to your Mom & to other old people in Liberty…we are Asian and we believe in kama, like in US said: GO AROUND COME AROUND…
        But when they pay then they have to pay double or triple time with what they done to the OLD…
        I am also sorry for your MOM and I believe she is rest in peace in the heaven and she is looking down to follow you & Your family everywhere you go & protect you. We Asian we believe that. Because our soul live forever to pay for what we done bad or what we done good.
        My Dad always tell me since I was a little girl until the last day with me in the hospital that” BE GOOD,BE HONEST,BE STRAIGHT ALWAY IN ANY SITUATION,BECAUSE EVERYTHING WE DONE IN THIS LIFE WILL SAFE IN THE HEAVEN BANK RECORD…” even some time I am so much angry to ask my Dad that “DID YOU TEACH ME WRONG? WHY I GOT CHEATED WITH PERSON WHO I HELPED THEM & THEIR FAMILY” (Because I was helping a person in business with his family in bad situation no food-no money to pay electric/water or children to go to school. But in the end he took money from my partner and I have to pay back in suffering pain in vein for 3 years for the amount 2M USD)
        You can’t imaging how I was suffering for that time. But it’s passed and I still stand on my feet but that person now living with his family in difficult situation even worse than before…that we called KAMA…
        Keep praying for your Mom and I will light the candle for your Mom too in the PAGODA when I go there to pray for her soul & your family as well…
        Be strong , Be happy (I knew it’s hard with painful in our heart)we still have to move on in life… believe me that your MOM is always with you
        Best Regards
        Vivien Nguyen


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