Brighton Gardens of Charlotte

The facility failed to ensure proper referral and follow-up to meet the health care needs of residents. Specifically, the facility failed to ensure follow-up with a physician for two residents, including one resident who missed sliding scale insulin (SSI) for nine days and another resident who required physical, occupational, and speech therapy following a fall but did not receive the necessary evaluations or follow-up documentation.

The facility failed to ensure necessary medical follow-up and referrals for residents. Specifically, one resident missed sliding scale insulin (SSI) doses for 9 days, and another resident did not receive the required follow-up evaluations for physical, occupational, or speech therapy following a fall.

The facility failed to ensure proper referral and follow-up with a physician for a resident with high blood sugar levels. Specifically, for one resident, there was no documentation that the Primary Care Provider was notified during multiple instances of hyperglycemia (FSBS > 401). Additionally, the facility could not provide a policy or procedure for managing diabetic residents with hypoglycemia or hyperglycemia.

The facility failed to ensure proper physician referral and follow-up for a resident with significantly high blood sugar readings. Specifically, for one resident, finger stick blood sugars were greater than 401 on 9 out of 17 occasions without documented follow-up. Additionally, the facility could not provide a policy for managing diabetic hypoglycemia or hyperglycemia.

The facility failed to ensure physician orders for continuous oxygen therapy were implemented for a resident. Specifically, the resident was observed without oxygen during transport, and staff were unaware of the continuous 3L order because it did not populate on the electronic medication administration records (eMAR).

The facility failed to ensure therapeutic diets were served as ordered for three residents requiring mechanical soft and consistent carbohydrate diets. Specifically, Resident #11 was served non-compliant items including a fried egg roll with a hard crust, unpureed vegetable beef soup, and dry crackers. The Dining Services Coordinator admitted that facility-created entrees were not reviewed by a Registered Dietitian for appropriateness.

The facility failed to ensure therapeutic diets were served as ordered for 3 of 4 sampled residents. Specifically, Resident #11, who was prescribed a No Added Salt (NAS) mechanical soft diet, was served items including a hard-crust egg roll, unpureed vegetable beef soup, and dry crackers.

The facility failed to provide adequate supervision for residents in the special care unit, resulting in two residents eloping from the unit and the facility. This occurred because the main exit door had a delay in its locking mechanism, and staff failed to monitor the door effectively to prevent unauthorized exits.