The Gardens of Statesville

The facility failed to ensure follow-up with the primary care provider for two residents regarding medication refusals and weight gain. Specifically, for one resident, multiple instances of insulin refusals were documented without evidence of physician notification or follow-up as required by facility policy.

The facility failed to ensure necessary follow-up with primary care providers for residents experiencing significant health changes. Specifically, the facility did not notify physicians regarding insulin mealtime refusals for Resident #2 and weight gain of more than one pound for Resident #1.

The facility failed to access the Health Care Personnel Registry (HCPR) to ensure no substantiated findings existed before hiring one sampled staff member. Consequently, there was no documentation to prove a required background check was completed prior to the employee's start date.

The facility failed to ensure necessary follow-up and referral for physician-ordered lab testing for a resident taking Coumadin. Specifically, there were no weekly PT/INR results recorded in the resident's record despite physician orders for monitoring. This lack of monitoring was evidenced by bruising observed on the resident's hands.

The facility failed to ensure necessary referral and follow-up for a resident taking Coumadin, specifically failing to obtain physician-ordered PT/INR lab testing. As a result, the resident had not had required blood work performed since admission, and bruising was observed on the resident's hands.