MOUNT OLIVE CENTER
LOCATED: 228 SMITH CHAPEL ROAD BOX 569, MOUNT OLIVE, NC 28365

MOUNT OLIVE CENTER 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 GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES.

LEVEL OF HARM – ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on staff interview and record review the facility failed to make changes in the treatment of [REDACTED]. #1) with pressure ulcers.

Continuing: Review of the Skin Integrity Reports revealed Resident #1’s sacral pressure ulcer was not assessed between [DATE] and [DATE]. Resident #1’s [DATE] quarterly MDS documented her cognition was moderately impaired, and she had a stage II pressure ulcer. On [DATE] the facility began to follow the treatment recommendations made by the wound clinic on [DATE] and [DATE] for skin prep and sensicare to the periwound/ [MEDICATION NAME] or Promagran to the wound bed/xtrasorb foam dressing every three days. On [DATE] Resident has actual skin breakdown related to incontinence, vascular disease, limited mobility, refuses incontinent care at times; resident has a pressure ulcer on her sacrum was identified as a problem on the resident’s care plan. Interventions to this problem included Provide wound treatment as ordered, Weekly skin assessment by licensed nurse, and Weekly wound assessment to include measurements and description of wound status. Resident #1’s Skin Integrity Report documented on [DATE] her sacral wound had declined to a stage III pressure ulcer measuring 1.8 x 1.5 x 0.3 cm with 75% [MEDICATION NAME] tissue and 25% slough in the wound bed. Review of the Skin Integrity Reports revealed Resident #1’s sacral pressure ulcer was not assessed between [DATE] and [DATE]. [DATE] and [DATE] the wound clinic recommended continuing its [DATE] and [DATE] recommendations for the treatment of [REDACTED]. These recommendations were signed off on by Resident #1’s primary physician team. Change dressing every other day or as needed for excessive drainage. Review of Resident #1’s May and [DATE] TARs revealed the facility continue to change the dressing to the sacral pressure ulcer every three days. A [DATE] physician progress notes [REDACTED]. May d/c (discontinue) wound clinic and continue current care and monitoring with staff. Resident #1’s Skin Integrity Report documented on [DATE] the resident had a stage II sacral pressure ulcer measuring 1.0 x 0.6 x 0.2 cm with greater than 75% granulation tissue in the wound bed. Record review revealed no further assessments of the resident’s sacral pressure ulcer until she expired in the facility on [DATE]. At 4:12 PM on [DATE] the director of nursing (DON) stated per facility protocol pressure ulcers were to be measure and assessed weekly. She also reported when members of the primary physician team signed off on consult recommendations, the facility was supposed to follow them. The DON commented she could not explain why the facility did not follow wound clinic recommendations for treatment of [REDACTED]. The DON stated these recommendations should have been followed by the facility since all of them were signed off on by the resident’s primary physician team. At 4:20 PM on [DATE] Unit Manager #1 stated wounds were to be measured and assessed weekly. She reported this was important to capture any decline in the wounds quickly and react by possibly changing treatments/frequencies and increasing nutrition interventions to promote healing. She explained she was the only unit manager in the facility for a long period of time, and she did the best she could, but was not always able to assess wounds/pressure ulcers weekly per facility protocol. According to this unit manager, when members of the primary physician team signed off on consult recommendations, the facility was supposed to follow them.

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

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