Nursing home put residents in ‘jeopardy’ on the night two were found dead, NC says

A short-staffed nursing home in Thomasville put its residents in “immediate jeopardy” when it failed to enact an emergency plan, leaving just three people to take care of 98 residents during a January storm, state regulators say.

Shortly after 8 p.m on Jan. 16, police arrived at Pine Ridge Health and Rehabilitation Center to investigate a 911 call from a resident who complained of not having seen staff members at the facility for a “long period of time,” according to a state report released Monday.

Police officers found two residents dead and two others in critical condition inside the for-profit nursing home, located about 70 miles northeast of Charlotte.

The inspection report describes a chaotic scene at the nursing home that day: Residents without food and needed medications; an exhausted nurse aide who suffered a panic attack; patients wandering in the dementia unit, putting unidentified items in their mouths.

A police officer said the one nurse on duty at the time had been working for 16 hours and “almost broke down into tears,” according to the state Department of Health and Human Services report.

The nurse told an officer the situation was “one of the worst things she had ever seen,” the report said.

The officer said five or six call lights were on in the hallway, some rooms smelled of urine and feces, and others had garbage on the floors, the report said.

Another officer found residents had been crying, saying they had not received food or medication that day.

“The police officer inquired to her if the residents had been fed and the nurse responded they had received breakfast but had not had lunch or dinner,” the report stated.

In a written statement, Pine Ridge Health said it experienced “a perfect storm of challenges” that night due to the weather, a surge in COVID-19 cases and an increased reliance on contract agency staff.

“We take the state’s concerns very seriously and are responding to areas identified by regulators,” the statement said. “We are working diligently to take meaningful steps to ensure all residents are receiving the medical care and support they need.”

The report does not specify the causes of death for the two deceased residents. A previous statement by Pine Ridge Health said the deaths were “medically unrelated” to any staffing issues caused by the storm. The families of residents who died were notified at the time of death, the nursing home said.

Three days earlier, the report noted, Gov. Cooper had enacted a state of emergency for North Carolina because of the predicted winter storm. But the nursing home failed to plan for the inclement weather, leaving it badly understaffed on Jan. 16, the report concluded.

On Tuesday, Emery Milliken, deputy director of N.C. Division of Health Services Regulation, said the nursing home had extra pay for workers to sleep over during storms, but Pine Ridge Health leaders never told staff of that perk.

Pine Ridge Health usually has 13 to 15 staff on site — not three, Milliken told the Joint Legislative Oversight Committee on Health and Human Services.

She said many residents depend on staff to eat and stay clean.

“This is the most vulnerable population,” said Sen. Steve Jarvis at the hearing Tuesday. “What if that was my mother? What if that was your mother?”

An administrator at the home told inspectors the nursing home had been “fully staffed on paper.” But the staff scheduled to arrive on the morning of Jan. 16 didn’t come in, the administrator told investigators, the DHHS report said.

The director of nursing said she had called staff to instruct them to come to work, but some didn’t answer their phones and others said they couldn’t make it because of poor road conditions.

The nursing director said the facility had been short staffed since the summer, and that an administrator had been made aware of the problem but had never addressed staffing.

More staff began to arrive at Pine Ridge Health around midnight that chaotic January night. And by midday Jan. 17, the home was sufficiently staffed, administrators told investigators.

“The facility implemented staffing meetings to review sufficient staffing for shifts going forward...” the inspection report said, adding that the nursing home’s administrator and director of nursing no longer work there.

Investigators said eight violations at the nursing home rose to the most serious level — “immediate jeopardy” — meaning the problems left patients at risk for serious harm or death. Five more violations were less severe.

The nursing home acknowledged the problems, according to the state report, and has taken steps to bring the facility back into compliance.

Milliken told committee members Tuesday that the most series deficiencies have been addressed, but the home has not corrected some of the less severe problems.

Because of that, the Centers for Medicare & Medicaid Services, which regulates most nursing homes, has stopped funding new admissions at Pine Ridge Health. The federal agency is also assessing monetary fines until the nursing home is in “substantial compliance,” Milliken said.

This story was updated to include information from a joint legislative committee hearing on March 15.

This story was originally published March 14, 2022 at 6:23 PM.