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Inspection finds resident was possibly seen eating a mouse at nursing home in Salisbury, family not immediately notified

The report says five of the 15 complaint allegations were substantiated resulting in deficiencies.
A newly-published inspection report states that an unannounced COVID-19 focused survey and...
A newly-published inspection report states that an unannounced COVID-19 focused survey and complaint investigation was conducted at Accordius Health at Salisbury on Statesville Boulevard from Aug. 12, 2021 through Sept. 3, 2021.(David Whisenant/WBTV)
Published: Oct. 29, 2021 at 1:18 PM EDT|Updated: Oct. 29, 2021 at 7:09 PM EDT
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SALISBURY, N.C. (WBTV) - An unannounced inspection found deficiencies in a report with several incidents including the handling of a situation when a resident was possibly seen eating a mouse and the failure to notify family of a resident’s positive COVID-19 status for months.

A newly-published inspection report states that an unannounced COVID-19 focused survey and complaint investigation was conducted at Accordius Health at Salisbury on Statesville Boulevard from Aug. 12, 2021 through Sept. 3, 2021.

The report says five of the 15 complaint allegations were substantiated resulting in deficiencies. The inspection report says “immediate jeopardy” was identified when a resident “ingested an unidentifiable object” and the facility failed to immediately and effectively respond to the situation.

The statement of deficiency details the treatment of one nursing home resident who was admitted to the facility on April, 1 2020 with diagnoses of dementia and psychosis.

*Warning, this story details graphic details of this incident. Reader discretion is advised*

According to the inspection report, a nurse practitioner’s Aug. 12, 2021 progress note revealed that this resident had ingested a rodent and vomited on Aug. 9, 2021. The note further revealed the nurse practitioner had called poison control regarding the possible rodent ingestion.

The report states that a nurse aide reported the resident had spit up “fur and grizzle that may have been a mouse’s tail” on Aug. 9, 2021.

The resident’s doctor was not made aware of the incident until the next day, according to the inspection report.

According to the inspection report, the nursing home’s director of nursing said she saw the resident in the hallway with a two-inch-long, dark-colored string hanging from his mouth on Aug. 9, 2021. She stated before she could stop him, he swallowed it. The report goes on to say she inspected his mouth but there was nothing in his mouth.

The director of nursing stated she reported the incident to the resident’s doctor when he came to the nursing home the next morning.

On Aug. 13, the inspection report says another nurse was interviewed, and she stated she cared for the resident on Aug. 9 when he ingested an “unidentified object” that day. She stated she did not report the incident to the resident’s doctor because she thought the director of nursing was going to do so.

The inspection report indicates that the nurse practitioner said she wasn’t told about the incident until Aug. 12, three days after the incident happened.

The nurse practitioner stated she was told by the director of nursing when she came to the facility to see residents, but she had not been called in to see the resident who possibly ate a mouse.

The nurse practitioner said she called poison control because she was concerned about the possibility the mouse could have been poisoned and the types of infections a mouse may carry. She said poison control told her that the resident should be monitored for fever, bloody stools and diarrhea. The nurse practitioner said she examined the resident on Aug. 12 for any bite marks on his face and in his mouth.

According to the incident report, a follow-up interview indicated that the director of nursing didn’t tell the family about the resident possibly eating a mouse until Aug. 12, three days after the incident happened.

On Aug. 17, the administrator was interviewed and stated the director of nursing should have told the resident’s doctor about the incident immediately on the same day it happened on Aug. 9, 2021.

In the case of another resident, the inspection report states this resident was admitted to the facility on Jan. 10, 2020 and his diagnoses included seizure disorder and a traumatic brain injury.

According to the inspection report, a nurse’s Jan. 12, 2021 progress note stated that this resident tested positive for COVID-19 and was taken to the COVID-19 quarantine unit. The nurse’s note did not specify if the family was notified of resident testing positive for COVID-19 or his transfer to the COVID-19 quarantine unit.

The inspection report states that seven months later, during an interview with a family member on Aug. 25, 2021, he stated he had not been notified that the resident had a positive COVID-19 test and was not notified the resident was moved to a COVID-19 quarantine unit on Jan. 12, 2021.

During an interview with the nurse on Aug. 26, 2021, she stated she could not remember if she had notified the family that the resident had a positive COVID-19 test or was moved to the COVID-19 quarantine unit on Jan. 12, 2021. The nurse stated she would have put it in her note if she had notified the family.

The administrator was interviewed on Aug. 27, 2021 and stated that the nurse should have notified the family of the resident′s positive COVID-19 test and his transfer to the COVID-19 unit. The administrator stated she was working in the facility when the resident tested positive on Jan. 12, 2021.

Several more details and incidents were detailed in the 51-page inspection report, you can read it below.

The inspection report gave a detailed description of the facility’s plan of corrective action for the deficiencies found with a provided date of compliance by Oct. 8, 2021.

Accordius Health’s plan of correction states that:

  • An audit will be completed of the current residents by the Director of Nursing/designee to ensure that physician and the resident responsible parties have been notified of changes in condition for the last 30 days to include ingestion of unidentified objects and notification of COVID-19 positive residents by Sept. 30, 2021.
  • The plan also states that the licensed nursing staff will be reeducated on ensuring the physician and the responsible parties are notified for resident changes in condition by the Director of Nursing or designee. The progress notes and risk incidents will be reviewed by the Director of Nursing/designee during morning clinical meeting Monday through Friday to ensure that resident responsible parties and the physicians are being notified for changes in condition using the morning stand-up sheet to monitor. Administrator or designee will review the previous 30 days of nursing notes to ensure notification has been done. This review will be completed by Sept. 30, 2021. Administrator has reeducated staff in regards to notifying all families of any positive COVID 19 test results. Administrator will review resident roster at time of any positive test results of COVID 19 to ensure all responsible parties or guardians have been notified of any positive case ongoing.
  • The results of the reviews of the progress notes/risk incident will be discussed in the monthly QAPI committee meeting for at least three months. The interdisciplinary team will recommend revisions to the plan as indicated to maintain substantial compliance.

A Salisbury attorney responded to an inspection report that found “disturbing deficiencies.”

Mona Lisa Wallace, from Wallace & Graham, P.A., sent a statement to WBTV saying, in part, “Unfortunately, these sort of citations almost always stem from underlying problems including chronic understaffing and lack of adequate financial support.”

Here’s the full statement from Mona Lisa Wallace, from Wallace & Graham, P.A.:

“Deficiency citations of this degree are extremely disturbing not only for the residents of this facility, but also for the families with loved ones living in these conditions. Unfortunately, these sort of citations almost always stem from underlying problems including chronic understaffing and lack of adequate financial support. The number one impact on resident quality of care in nursing home is staffing. During a time where COVID-19 continues to limit access to loved ones in nursing homes, it is crucial that these facilities comply with the North Carolina Residents’ Bill of Rights and increase transparency with those outside the facility.”

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