Tyrrell House

The facility failed to ensure that 2 of 6 sampled staff members (Staff B and Staff E) were verified against the North Carolina Health Care Personnel Registry (HCPR) upon hire. Personnel files for these employees lacked documentation of the required registry check at the time of their employment start dates.

The facility failed to ensure referral and follow-up to meet the acute health care needs of one sampled resident. Specifically, there was no documentation provided to show that the primary care provider was notified regarding a resident who was sent to the emergency department due to vomiting.

The facility failed to ensure that all staff members were verified against the North Carolina Health Care Personnel Registry (HCPR) upon hire. Specifically, a review of personnel files for two medication aides revealed no documentation of an HCPR check at the time of their employment.

The facility failed to ensure provider notification and follow-up for two residents. Specifically, one resident's worsening pressure wound was not reported to the primary care provider, and another resident's return from the emergency department following an episode of blood in the urine was not reported to the primary care provider.

The facility failed to ensure provider notification and follow-up for two residents. Specifically, a resident with a worsening pressure wound was not reported to the primary care provider, and a resident returning from the emergency department was not reported to their physician.

The facility failed to maintain a safe environment by storing four portable oxygen tanks unsecured on the floor in a resident's room. These tanks were not placed in the required storage racks, creating a potential hazard. Staff interviews indicated a lack of awareness regarding the proper storage of these tanks and a failure to identify the hazard during daily walkthroughs.

The facility failed to provide personal care to a resident according to their care plan. Specifically, one resident who required extensive assistance with bathing and grooming was observed with dirty hands, dirt under fingernails, and stained clothing, indicating a failure to provide necessary showering assistance.

The facility failed to ensure a resident received necessary assistance with showering and grooming as required by their care plan. Observations revealed the resident had dirty hands, dirt under his nails, and was wearing stained clothing and unwashed clothes from a previous day. Staff failed to adequately address the resident's refusal of care or ensure personal hygiene needs were met.

The facility failed to provide adequate supervision for a resident who had at least ten falls resulting in five emergency room visits and serious injuries, including fractures and head injuries. There was no assessment or documentation of the resident's specific needs regarding supervision or fall precautions despite the resident being ambulatory and prone to wandering.