Fondling, falls and fights: What Fayetteville veteran home's has been cited for in past

As 85 residents are moved from the North Carolina State Veterans Home in Fayetteville by February because of “ongoing repair,” records with another state agency show the facility has been cited for multiple deficiencies in the past three years.

According to the North Carolina Department of Health and Human Services’ Nursing Home Licensure and Certification section, the last deficiency issued for the Fayetteville veterans home was Aug. 17.

In a Nov. 22 statement, Kelly Haight Connor, a spokeswoman for the North Carolina Department of Health and Human Services, said DHHS conducts “routine and complaint inspections at facilities."

“Complaints ... are confidential and we can’t comment on complaints, investigations or possible investigations,” Conner said. “All complaints are carefully reviewed and triaged for appropriate follow up.”

The North Carolina Department of Military and Veterans Affairs oversees the Fayetteville home, which is managed by PruittHealth.

With each allegation, PruittHealth wrote a plan of correction to comply with federal and Medicaid requirements.

PruittHealth said that executing the correction plan did not “constitute admission or agreement by the provider of the truth of items alleged or conclusions set forth the alleged deficiencies.”

“The plan of correction is prepared and/or executed solely because it is required by the provision of the state and federal law to remove substantial noncompliance,” PruittHealth said in its correction plan. “It also demonstrates our good faith and desire to continue to improve the quality of care and services for our residents.”

Not updating records

According to the NCDHHS records, the facility was cited in August for failing to accurately update a resident’s dental records.

The citation stated that the resident’s last dental visit was Oct. 7, 2022, when he requested root tips be taken out so he could get dentures.

During an Aug. 14 interview, the resident told officials there were some broken teeth and others were gone and he was observed to have several missing teeth and a chipped front tooth.

The citation noted that care plans for two other residents were not updated properly.

According to NCDHHS, an administrator told state officials on Aug. 17 that the deficiencies were addressed.

Inappropriate touching

A July 17 DHHS citation notes that the facility was noncompliant from May 1 until June 1 after one resident was coerced into fondling another resident. The citation stated that before the May 1 incident, staff had observed one of the residents with his hand below the waistline of the other resident on Feb. 13.

According to the record, Resident 8, which is how the individual was identified in the record, was "moderately cognitively impaired" and had been diagnosed with a sexual disorder on Aug. 22, 2022. The record said the resident had a history of inappropriately touching staff and asking others to perform sexual acts on him.

The NCDHHS record stated that a nurse noted she had seen a severely cognitively impaired resident, identified as Reisdent 11, touching the lower half of Resident 8's body and Resident 11 said Resident 8 would ask him to massage his shoulders and back.

A psychiatric nurse practitioner noted that as a result, Resident 8 was prescribed medication used for sexual aggression and she recommended increasing his medication and placing him on another medication used for patients with dementia who displayed sexual behaviors.

The citation stated that before Feb. 13, there had been no indication of Resident 11 touching Resident 8 sexually.

The nurse practitioner told investigators that Resident 11 was easily persuaded and that Resident 8 could have lured him into the room.

The citation states that Resident 8 apologized when confronted, but that “it was hard to determine if he knew what he was doing." The citation said Resident 11 did not recall what happened Feb. 13.

The citation states that the two residents were moved to rooms further away from each other, but on May 1, a nurse aide found Resident 11 once again fondling Resident 8 in Resident 8's room.

The NCDHHS citation states that the facility’s medical director reported that staff was made aware of Resident 8's “atypical behaviors,” which they thought were a “manifestation of his advanced dementia.”

According to a July 17 corrective action plan, Resident 8 was placed on one-on-one supervision and referred to psychiatric services. He was seen multiple times by a psychiatrist from May to July and two times for psychotherapy in May, the record states.

An "intent to discharge notice" was issued to discharge the resident from the home to a psychiatric facility, the record states.

As a result of the incidents, Resident 11 was also seen by psychiatric services multiple times in May, June and July and the staff was educated on sexual behaviors and de-escalation.

"Based on observation, record review, staff interview, Psychiatric Nurse Practitioner interview, and Medical Director interview, the facility failed to protect the rights of a severely cognitively impaired resident to be free of abuse," the NCDHHS found. "The reasonable person concept was applied to this deficiency as individuals would 1) not want to be coerced into performing sexual acts for others and 2) not want to be taken advantage of sexually when they lacked the cognitive ability to make sexual decisions."

Patient fall

According to a Nov. 4, 2022 report, the facility was in noncompliance from Sept. 27, 2022, to Oct. 29, 2022, because staff failed to notify a physician that a resident had fallen.

The resident, who was diagnosed with Parkinson’s, dementia, tremors and uncontrolled body movements, suffered from multiple facial bone fractures in a fall on Sept. 27, 2022, the record said.

The resident also had an “altered” mental status change after being hospitalized for cranial surgery earlier in September, DHH’s citation stated.

The citation noted a lack of communication between employees.

A nursing supervisor said she learned about the investigation of the residents’ care by his administrative staff because bruises appeared on the resident's face following her dayshift.

The nursing supervisor said that while she observed the resident’s nosebleed, no one had reported the fall.

The facility’s administrator told investigators there was a lack of communication between staff about the residents’ fall, and investigators noted staff members reporting “different scenarios,” with a nursing assistant saying a nurse knew about the fall, while the nurse denied that she did.

The resident was taken to the hospital Sept. 28, where a scan showed multiple fractures.

According to the citation, interventions were put in place to limit the risk of falling, and certified nursing assistants and licensed nurses were educated about eliminating the risks and ensuring proper communication.

Other deficiencies

A May 31, 2022, NCDHHS citation found that staff did not honor a resident’s request to get out of bed in April 2022.

The resident, whose medical records noted he needed extensive assistance with daily living activities, told investigators that nursing assistants told him not enough staff were available to help him get out of bed.

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A nursing assistant told investigators that during the weekend when the resident wanted to get up, she only had four nursing assistants available to look after 25 residents.

The director of nursing told investigators that there were enough employees in the facility, but they were not in the right areas and that nursing assistants were not in soon enough to get residents their morning care.

The May 2022 citation also noted a separate incident found that one resident was allegedly abusing another resident by hitting the resident in the arm, causing a skin tear at the elbow on May 27, 2021, and kicking the resident in the face on Nov. 30, 2021, causing a bloody nose.

The NCDHHS report stated that the alleged aggressor was diagnosed with schizophrenia and dementia with behavioral disturbance and that after the May 2021 incident, a stop sign was placed at the entryway of his room to keep other residents from entering.

The report also notes a separate resident hitting another resident in March 2022, after the resident took his iced tea.

The director of nursing told investigators that the alleged aggressor was monitored because of having a history of not wanting others to touch his items, while an administrator said the resident had been moved from his room several times because of not getting along with roommates.

The resident was monitored three times in April, with no behavioral concerns noted.

Other deficiencies noted in the May 2022 citation found instances of records being properly updated for two residents after they were discharged from hospitalization; and care plans did not note a device a resident needed for foot care.

COVID-19 deaths

While the Department of Veterans Affairs reported that the Fayetteville veterans home had 30 COVID-19 related deaths during the height of the pandemic from May 25, 2020, to Aug 29, 2021, unannounced COVID-19 surveys conducted on Nov. 15, 2021, Dec. 18, 2020, and May 19, 2020, found the facility was complying with NCDHHS guidelines.

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How the home rates

The Joint Commission on Accreditation of Healthcare Organizations, a nonprofit that certifies healthcare facility accreditations, found no issues with the Fayetteville veterans home during a November 2021 visit.

The commission found the facility met its 2021 national patient safety goals.

U.S. News & World Report gives the facility an average three out of five stars based on hospitalizations, staffing, flu vaccines, use of antipsychotic drugs and health deficiencies.

The VA's Access to Care rates the facility two out of five stars overall, while giving four stars for quality and staffing and two stars for survey.

Staff writer Rachael Riley can be reached at rriley@fayobserver.com or 910-486-3528.

This article originally appeared on The Fayetteville Observer: NC reports reveal Fayetteville vet home's history of citations