Spring Arbor of Cary

The facility failed to ensure the acute healthcare needs of a resident were met by failing to schedule a necessary neurology appointment. Following a fall on 08/21/24 that resulted in a hospital visit, the Emergency Department recommended a neurology follow-up for potential hydrocephalus, but no neurology visit notes were available for review.

The facility failed to ensure the acute healthcare needs of a resident were met by failing to schedule a required neurology appointment following an emergency department visit. Although the hospital recommended a neurology follow-up due to potential hydrocephalus after a fall, there was no documentation that the facility contacted the specialist or coordinated the referral.

The facility failed to provide adequate supervision of residents based on their assessed individual needs, care plans, and varying symptoms. Staff must ensure supervision levels match the specific requirements of each resident.

Resident care and supervision needs must be reassessed regularly by the nurse or resident care director. Any increases in supervision needs must be addressed with interventions implemented as needed.

The nurse care director or designee must maintain a current tracking system to ensure timely reassessments and updates of care plans and T/W logs.

The nurse director or nurse care director or designee must conduct routine audits to ensure compliance with monitoring visits to the community.

The facility failed to provide adequate supervision for 3 out of 5 sampled residents in accordance with their care plans. This failure included residents who experienced high frequencies of falls resulting in injuries, hospitalizations, and emergency room visits.