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Nurse #2 reported, she read the upper part of the result and missed the lower part

SUNNYBROOK REHABILITATION CENTER

LOCATED: 25 SUNNYBROOK ROAD, RALEIGH, NC 27610

SUNNYBROOK REHABILITATION 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 PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT

LEVEL OF HARM –IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews, staff interviews, physician interviews, and x-ray facility staff interviews, the facility failed to identify the need for a medical intervention for 1 of 3 residents (Resident #1) with a significant change of condition of increased pain and swelling to bilateral knees after sustaining a fall. The Immediate Jeopardy began on 8/3/15 when the resident developed pain and swelling after a fall. The resident had a positive x-ray result of a right fractured femur and she did not receive medical attention until 8/6/15. The immediate jeopardy was removed on 9/3/15 when the facility provided a credible allegation of compliance.

During an interview on 8/19/15 at 2:15 pm, with Nurse #2, the nurse revealed she ordered an x-ray on 8/3/15 due to the increased pain and swelling the resident had to her knees. The nurse ordered this x-ray at 9:15 am on 8/3/15 per the record review of the physician’s order [REDACTED]. The nurse reported she looked at the results quick and she thinks she faxed it to the doctor, but she could not remember. The nurse further added that she showed the results to the physician on 8/6/15 when the physician was at the facility. The nurse reported the resident was complaining of pain in the left knee and the physician ordered an x-ray on 8/6/15 of the left leg. The nurse was asked what the process was when you order an x-ray with the x-ray company. The nurse reported that first, you order the x-ray by phone, and the x-ray company will come to facility and do the x-ray. The x-ray company will fax the results to the facility. The nurse reported the nurse is to go to the fax machine and get the results or they are delivered to the nurse ‘ s station by the administrative staff. The nurse was asked why she did not get the results until after 10:00 pm when it was faxed from the x-ray company to the facility at 12:57 pm. The nurse replied, sometimes the nurses do not have time; the fax machine is on the other end of the room.

During an interview on 8/19/15 at 3:00 pm, with the physician, it was revealed she was not aware of the x-ray result on 8/3/15. The physician added that if she had known about the acute fracture to the right femur she would have ordered the facility to send the resident to the hospital right away. The physician recalled being at the facility on 8/6/15 and being told the resident was having knee pain. The physician reported she ordered an x-ray for the resident and it showed a left fractured femur. The physician reported she was shown the x-ray result from 8/3/15 on 8/6/15 by Nurse #2. The physician asked why she was not told about the 8/3/15 result and Nurse #2 reported, she read the upper part of the result and missed the lower part. The physician reported her expectation of the nurses is to report any abnormal diagnostic test or lab value immediately to the doctor via phone or fax.

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.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

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