Final report detailing traumatic scene at Pine Ridge nursing home released
North Carolina’s Department of Health and Human Services has released their report describing the chaos at Pine Ridge Nursing and Rehabilitation Center on January 16; the night two residents were found dead. Two others were found in critical condition.
The 159 page document provides insight into what took place at facility that led to the gruesome discoveries. Text messages between staff and administrators, calls to 911 from residents and statements from onsite staff outline how residents were put into “immediate jeopardy” when the center failed to enact its Emergency Preparedness Plan. Three days prior, Governor Roy Cooper had declared a state of emergency ahead of a predicted winter storm.
Among the statements found in the document:
A responding officer noted it was an “emotional ordeal at the facility.” He observed residents crying saying they had not received medications or food that day and the facility smelled horribly of urine and feces.
The one nurse who was working nearly broke down into tears when officers arrived. She said after she explained what had happened to the police officer, he was able to get assistance, and she was so glad to see those Police Officers, Fire Department and Emergency Medical Services (EMS) enter the facility because they had come to help take care of the residents.
One of the nursing assistants on duty revealed he and the nurse had to make sandwiches for the residents because they had not found any prepared meals for dinner on 01/16/22. He also explained he worked as quick as possible and tried to get to each resident timely to provide care but that was not possible, and residents were unhappy. The nursing assistant said residents were complaining because they had to wait for care and for food, but they thanked him for all that he was able to do for them.
The former Director of Nursing revealed she had been made aware earlier in the previous week about the possibility of a winter weather storm, she believed Administrator #2 (as listed in the document) was aware of the pending winter storm, but she had not discussed any of the preparations with her. The DON revealed on 01/16/22 she received a phone call from the nurse and was informed of the poor staffing at the facility. The DON added she tried to drive to the facility after she was called, she thought it was shortly after 7:00 AM, but the roads were icy, and she turned around and went home.
A phone interview conducted on 01/26/22 with the DON (Director of Nursing) #1 revealed the facility had been short staffed since the summer and Administrator #2 was made aware but never addressed staffing. The DON revealed that the facility never experienced a staffing shortage like they did on 01/16/22 even with staff from agencies. The DON revealed she and Administrator #2 never spoke about plans for staffing or plans for staff transportation prior to the winter storm on 01/16/22.
In the document, there is acknowledgement by Pine Ridge of the report. It reads “Pine Ridge Health and Rehabilitation Center acknowledges receipt of the Statement of Deficiencies and proposes this Plan of Correction to the extent that the summary of findings is factually correct and in order to maintain compliance with applicable rules and provisions of quality of care of residents and to meet requirements established by state and federal law. The Plan of Correction is submitted as a written allegation of compliance.”
