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Operation Guardians Reports


Plott Nursing Home – Ontario

Summary

“At the present time, residents are being avoidably harmed due to deficient nursing care in a number of aspects, including pressure ulcer prevention and treatment.” During the inspectors’ stay at Plott Nursing Home, only one RN was on duty providing direct resident care. The absence of a person capable of medically evaluating residents has had adverse effects on the quality of care received by the residents. For example, one resident had a stroke at 4 A.M. The LVN (who is not legally permitted to make a medical evaluation) falsely believed the resident had only suffered a Transient Ischemic Attack. Because of the false diagnosis, the resident was ignored for the duration of the nurse’s shift. When a new nurse arrived, the resident displayed “neurological deficits.” The new nurse called for the resident’s transportation to a local hospital, where he was properly diagnosed with a stroke. However, the more time it takes to receive treatment after a stroke, the less effective the treatment will be, thus the resident was put at unnecessary risk because of the facility’s staffing deficiency.

The deficient staffing also contributes to the facility’s inability to properly diagnose and treat pressure sores. One resident, who had arrived to the facility with zero pressure sores, acquired two sores a mere two months after his arrival. During the two-month period, some of the routine measures to treat pressure sores were never documented. Another patient’s pressure sore more than doubled in size a mere month after being admitted to the facility. Two weeks later, he was transferred to the hospital with septic shock due to an infection from the sore. He died the day following his transfer to the hospital.

In another instance of resident neglect, a patient who had complained of burning during urination was not given a urinalysis until eleven days after his initial complaint. Finally, several residents complained that staff members had stolen their personal property. Some residents even placed “please do not steal” notes on their belongings. When inspectors spoke with residents, it seemed the residents were fearful of retaliation. “It appears there is a possibility that residents are being verbally harassed and intimidated by the facility staff.”