Brookdale South Charlotte

The facility failed to notify the primary care provider (PCP) regarding elevated finger stick blood sugars for a resident. Despite physician orders to call the PCP if evening readings exceeded 200, there was no documentation that the provider was notified of multiple elevated readings between August and October 2024.

The facility failed to ensure the medication administration record (MAR) was accurate and included necessary instructions. Specifically, the facility failed to maintain records of physician notifications related to medication parameters and failed to ensure staff were trained on after-hours communication protocols.

The facility failed to notify the primary care provider (PCP) regarding elevated finger stick blood sugar (FSBS) readings for a resident. Despite physician orders to call the PCP if evening readings exceeded 200, there was no documentation of notification for multiple elevated readings across August, September, and October 2024. The resident's PCP confirmed they were never contacted by the facility regarding these specific elevations.

The facility failed to ensure physician's orders were implemented for a resident. Specifically, the facility did not follow an order for daily blood pressure readings and failed to monitor heart rate before administering medication that required both blood pressure and heart rate monitoring.

The facility failed to ensure physician's orders were implemented for a resident requiring blood pressure and heart rate monitoring before administering Atenolol. Specifically, there was no documentation that blood pressure or heart rate was taken daily, and no entry recorded the instruction to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 50.

The facility failed to ensure physician's orders were implemented for a resident requiring blood pressure and heart rate monitoring before administering Atenolol. Specifically, there was no documentation that blood pressure or heart rate was taken daily, and no entry recorded the instruction to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 50.

The facility failed to implement CDC and NC DHHS guidance regarding COVID-19 infection control during an outbreak. Specifically, the facility did not rapidly re-test residents and staff who tested negative 3-7 days after an outbreak and failed to properly screen staff upon entry.

The facility's COVID-19 Outbreak/Cluster Worksheet-Initial Notification form dated 07/17/20 documented an outbreak involving 4 staff members testing positive for COVID-19. The review focused on the clinical management and implementation of infection control interventions following symptom onset between 06/28/20 and 07/07/20.