The Terrace Transitional

October 8, 2024 · Complaint, Investigation Inspection

• High Provider shall protect clients from abuse, prevent abuse(R380-80-5(4))

  Based on interview and record review, it was determined there was a delay in care for a resident complaining of leg numbness and weakness for 1 of 4 sampled residents. Resident identifier: 1. Findings Include: Resident 1 was admitted to the facility on 5/17/2024 and discharged on 6/30/2024 with diagnoses of wedge compression fracture of the thoracic (t) vertebra of t7-t8 , multiple rib fractures, muscle weakness, cognitive communication deficit, and schizophrenia. On 6/26/2024 at 12:38 PM, a provider documented a cranial nerve exam and neurological exam was conducted on resident 1 due to complaints of being unable to move or feel their legs for the last day. The provider documented no abnormalities were noted. Resident 1 had been able to feel and move their lower extremities at the time of the exam. On 6/29/2024 at 4:48 AM and 11:54 AM, licensed practical nurses documented resident 1 had complained of lower extremity paralysis. There was no provider documentation or communication located to indicate the provider had been made aware of resident 1's change of condition. On 6/30/2024, a registered nurse documented resident 1 had been seen by the provider and sent to the emergency room due to hypoxia, nausea, and new onset paralysis to lower extremities. At 1:30 PM, the provider documented resident 1 had been sent to the emergency room due to a new diagnosis of peripheral neuropathy and no movement to their lower extremities post vertebral compression fracture. It should be noted resident 1 had a 5 day hospital admission with diagnoses including but not limited to Cauda equina compression, epidural abscess, and osteomyelitius of the thoracic vertebra. On 10/7/2024 at 2:19 PM, an interview was conducted with the Administrator (ADM). The ADM stated they were recently made aware that resident 1 had made claims of a fall at the facility and staff had not been taking care of them. The ADM stated there was no documented incident of a fall and there had been no report of a fall. On 10/7/2024 at 2:42 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated the last encounter they had with resident 1 was when resident 1 voiced they were unable to move or feel their legs and the NP observed a lack of movement in resident 1's lower extremities. The NP stated they sent resident 1 to the hospital but they were unsure if resident 1 was faking or exaggerating their symptoms. The NP stated they remembered they rounded on resident 1 on a Sunday and immediately sent them out that day due to their symptoms and their past medical history. The NP stated resident 1's lumbar back all of a sudden got worse and they were unable to move their legs and with their history, they knew this was going to happen eventually. On 10/8/2024 at 9:48 AM, a follow up interview was conducted with the ADM. The ADM stated they were unable to provided further documentation to show the provider had been notified of resident 1's condition on 6/29/2024.

  How was this corrected? On 11/27/24, the licensor verified the facility was in compliance with protecting resident's health and safety by monitoring for change of condition and notifying the physician, as stated in rule

  Corrected on November 27, 2024, verified by the state.

September 18, 2024 · CMS Federal Survey Inspection

No citations from this inspection.