May 16, 2022


The home veterans

At NC nursing home so understaffed that it endangered residents, there was an emergency plan. ‘No one looked at it.’ | State and Regional News

7 min read

The for-profit owner of Pine Ridge Health and Rehabilitation is facing an undisclosed set of penalties after state investigators said the center failed to meet multiple standards aimed at keeping residents safe.

Those include failing to follow its emergency preparedness plan, which has a section for dealing with inclement weather and allows for additional staff to be compensated with “sleep pay” so they can be snowed in at the facility.

Two Pine Ridge residents were found dead and two were hospitalized in critical condition on Jan. 16. The nursing home at 706 Pineywood Road in Thomasville had a total of three staff members to care for its 98 patients, officials said.

“What we found is that, although they had a plan, they never pulled it off the shelf. Staff didn’t know they had it, and no one looked at it,” Emery Milliken, deputy director of N.C. Division of Health Service Regulation, told the state’s Health and Human Services committee Tuesday.

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Milliken said that “the end result created a situation where there were so few staff present at the facility that residents made 911 calls to ask for help  … that they were wet and were hungry and hadn’t been fed.”

“The failure to enact the emergency plan meant residents did not receive medication and meals in a timely manner,” Milliken said. “They also didn’t receive other necessary care and services, and all residents were likely to suffer a serious adverse outcome based on the noncompliance with the regulations.

“It really was a failure at the facility to implement the plan that they had.”

Milliken also said additional medical staffers either didn’t come to work or left early because of the pending snowstorm.

Investigators identified “deficient practices” in at least 13 areas. Their report said that “every resident of the facility was placed at risk of severe harm.”

The federal Centers for Diseases Control and Prevention, which certifies long-term care facilities, has responded to the investigation by:

* Denying payment for new admissions since March 9

* Applying undisclosed fines “until the facility achieves substantial compliance”

* Notifying Pine Ridge it could lose Medicare payments “if the facility fails to achieve substantial compliance within six months.”

Pine Ridge has said it will put an approved corrective plan in place by March 22.

State health regulators will continue to conduct unannounced site visits to determine compliance with the plan.

Milliken said that fines and denial of payments will continue until the corrective plan is fully implemented.

Principle LTC, the Kinston-based owner of Pine Ridge, can appeal CDC penalties and sanctions.

The report

The division released a 159-page final report Monday.

Investigators conducted 89 interviews over more than 500 hours between Jan. 17 and Feb. 2 with nursing home residents, local law enforcement, local officials, emergency management responders and nursing home staff. They also listened to 911 calls from residents of the facility.

First responders said the two nurse aides on site were overwhelmed by the circumstances, having worked what became a 16-hour shift.

“This really was an extraordinary event,” Milliken said.

“You can’t read that report, and not feel a real sense of sadness for both what happened to the residents and for those three staff who were trying so hard to serve the needs of 98.

“It was truly a traumatic event for both.”

Investigators said Pine Ridge failed to comply with standards related to: emergency preparedness; keeping patients safe from abuse, neglect or exploitation; quality of life; quality of care; maintaining sufficient nursing staff; having sufficient dietary support workers; and administrative issues.

The facility also failed to meet standards related to resident rights, such as: notification of changes related to injury, a decline in health or room status; having a safe, clean, comfortable or homelike environment; and the frequency of meals or snacks.

New details

First responders were notified of the situation by 911 calls from residents who said they had not seen staff for several hours.

The first responders told investigators that the facility smelled “horrible” of “stool and urine” as they arrived between 8 and 10 p.m. Jan. 16. There was excrement on the floor in several locations, they said.

According to the report, several residents had not been fed lunch or dinner by the time first responders arrived, and residents with dementia were wandering the hallways.

Many residents had not had their medication and had not been seen by any of the three staff members at the time of the incident.

The report said Pine Ridge operators failed to heed a state of emergency declaration on Jan. 13 about the coming winter storm, primarily by not implementing an emergency preparation plan.

“Winter weather is rarely a surprise event and to make alternative staffing arrangements (is necessary) should a facility be cut off (meaning routes to and from the facility are impassable),” said the report.

Among new details provided during Milliken’s presentation: Pine Ridge should have had between 13 and 15 medical personnel on site during the winter snowstorm. That would include three nurses, two medication aides and eight to 10 nurse aides.

Staffing on the morning of Jan. 16 consisted of two registered nurses, two licensed practical nurses, two medication aides and two nursing aides.

By 2 p.m. Jan. 16, Pine Ridge had just one licensed practical nurse and two nurse aides on site.

Milliken said part of that inaction came from a change in facility administrator in August.

Milliken said that, in a nursing home setting such as Pine Ridge, many residents are “in the bed until you come to get them out. They are incontinent in bowel and bladder.

“If you don’t have staff there to give them assistance … a lot of these residents are totally dependent on care from the staff.

“The inadequate staffing was the reason … for a number of the citations that occurred,” Milliken said.

Pine Ridge officials told state regulators there were efforts made to bring additional staff to the facility, but they said roads were mostly impassable by the time of the 911 call to Thomasville police.

However, Thomasville police told investigators that roads were passable to the facility.

Pine Ridge response

Pine Ridge released a statement Monday in which it said the events of Jan. 16 represented a “perfect storm” of challenges from the weather, the COVID-19 pandemic and an increased reliance on contract staff.

“Pine Ridge has been working diligently to address issues that occurred,” the statement said.

“We take the state’s concerns very seriously and are responding to areas identified by regulators. We are working diligently to take meaningful steps to ensure all residents are receiving the medical care and support they need. We remain focused on the safety and wellbeing of our residents and staff.”

Principle LTC’s required emergency plan must include employee training at least annually and testing exercises at least twice a year.

According to the state report, Principle has suspended the nursing home’s administrator and nursing director.

Legislators’ response

Rep. Larry Potts, R-Davidson, and co-chairman of the Health and Human Services committee, requested a DHHS presentation on the investigation after being among the first elected officials called about the incident.

On Tuesday, Potts said that, although the division’s report “recognizes the need there, it doesn’t really share the extent of the damages that were done. I’ll leave it at that.”

Potts said Pine Ridge’s short-staffing during the incident wasn’t surprising given “it seems to be hard these days to gain adequate staffing for a nursing home.”

“It’s a difficult job that requires more pay to be able to find adequately skilled employees and staff levels,” Potts said.

Myers said potential staffing issues at long-term care facilities “are not new, with providers often competing for the same workforce.”

Myers said staffing shortages are impacted by low wages and mentally and physically difficult work — and a pandemic exacerbating the issue.

Sen. Steve Jarvis, R-Davidson, said he was disturbed by the failure of the facility administrator to implement the emergency preparedness plan.

Jarvis said he has been told by constituents that patient care had not been thorough at Pine Ridge prior to the incident.

Sen. Joyce Krawiec, R-Forsyth, said the state’s presentation “shed light on the serious tragedy that occurred at Pine Ridge.”

“I believe the investigation into this occurrence has been thorough and an in-depth correction action plan has been implemented. There are serious concerns about the quality of care that residents of Pine Ridge have received.

“We must make certain this can never happen again in North Carolina,” Krawiec said.


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