SPARTA, NC- LOTUS VILLAGE CENTER FOR NURSING AND REHABILITATION

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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Based on record reviews and staff, family member, Nurse Practitioner, Urology Surgeon, Wound Physician and Medical Doctor interviews the facility failed to protect a Resident’s right to be free from neglect when the facility failed to identify the seriousness of a left swollen testicle, complete thorough and ongoing nursing assessments, schedule a urology appointment per the Nurse Practitioner’s order which led to a delay in care and treatment for a serious medical emergency for 1 of 3 residents (Resident #1) reviewed for neglect. Resident #1 experienced a serious adverse outcome when an acute change in condition was noted on 03/11/24 with a blood pressure of 86/42 and weakness. The Resident was sent to the local emergency department where he was transferred to a hospital for a higher level of care and diagnosed with severe septic shock and urinary tract infection. An ultrasound showed no blood flow with necrotic changes to the left testicle and an orchiectomy (removal of the testicle) had to be performed. This practice affected 1 of 3 residents (Resident #1) reviewed for neglect.

Immediate Jeopardy began on 02/23/24 when the facility failed to protect a Resident’s right to be free from neglect when they failed to identify the seriousness of a left swollen testicle, complete thorough and ongoing assessments and schedule a urology appointment per the Nurse Practitioner’s order which led to a delay in care and treatment for a serious medical emergency. Immediate jeopardy was removed on 04/05/24 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included:

This tag is crossed referenced to:
F 684: Based on record reviews and staff, family member, Nurse Practitioner, Urologist and Wound Physician’s interviews the facility failed to identify the seriousness of decreased vascular flow to Resident #1’s left testicle and complete and document thorough and ongoing nursing assessments of left testicle after 03/23/24 to determine the need for further medical attention. In addition, a Urology Consultation for evaluation of the Resident’s left testicle was scheduled for after 3/23/24 not as ordered by the NP which further delayed the determination of what medical interventions were necessary. The Resident experienced an acute change in condition on 03/11/24 with a blood pressure of 86/42 (normal blood pressure range 120/80) and weakness. The Resident was sent to the local hospital emergency department (ED) and was then life flighted to a second hospital due to the need for a higher level of care and capabilities. The Resident was diagnosed with severe septic shock and urinary tract infection. A renal ultrasound showed an obstructing stone in the right ureter with hydronephrosis (excessive fluid in the kidney due to a backup of
urine) and a testicular ultrasound showed no blood flow with necrotic (death of cells or tissue due to disease or injury) changes to the left testicle. On 03/12/24 an emergency stent was placed in the right ureter and the left testicle was removed. This practice affected 1 of 3 residents reviewed for providing care according to professional standards of practice (Resident #1).

F 580: Based on record reviews, and staff, Nurse Practitioner, and Medical Doctor’s interviews the facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner’s order after a CT (computed tomography) scan noted decreased vascular flow to Resident #1’s left testicle. Resident #1 experienced serious adverse outcome after an acute change in condition was noted on 03/11/24 and was transferred to the hospital emergency department (ED), diagnosed with severe sepsis and underwent a left orchiectomy (removal of the testicle) on 3/12/24. This practice affected 1 of 3 residents (Resident #1) reviewed for notification.

The Administrator was notified of Immediate Jeopardy on 04/03/24 at 3:55 PM.
The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.

The facility failed to identify the seriousness of a swollen left testicle, complete thorough and ongoing assessments, schedule a urology appointment per the Nurse Practitioner’s order which led to a delay in care and treatment for a serious medical emergency.

On 12/21/23 Resident #1 was admitted to Lotus Village Center for Nursing and Rehabilitation with diagnosis of brain damage, dysphagia, hypertension and gastrostomy. On 2/19/24 the physician ordered Resident #1 to have urology appointment as soon as possible due to ultrasound showing possible decreased vascular flow to the left testicle. The facility scheduled the appointment for 3/27/24 and did not notify the ordering nurse practitioner of the delay between order and available appointment. Nursing staff did not complete ongoing and thorough assessments of the scrotal area to identify changes. On 3/11/24 Resident #1 had an acute change of condition noted with a blood pressure of 86/42 and weakness. Resident #1 was sent to the emergency room and was diagnosed with severe septic shock, urinary tract infection and aspiration pneumonia. Necrotic changes were found to the left testicle and removal of the testicle was performed.

Current residents residing in the facility have the potential to be affected by the deficient practice.