WRAL Investigates

'They may still be alive': Surprise nursing home inspections find potentially deadly mistakes

Posted February 4, 2021 4:07 p.m. EST
Updated February 8, 2021 1:55 p.m. EST

— Nursing homes account for more than one-third of all coronavirus-related deaths in North Carolina.

WRAL Investigates compared the state’s list of nursing homes to those identified with outbreaks on state reports and found just three out of more than 420 – Tower Rehabilitation and Nursing in Raleigh, Zebulon Rehabilitation Center in Wake County and Accordius at Asheville – were able to avoid an outbreak, which the state classifies as two or more related infections.

While the success stories are a short list, WRAL Investigates found plenty of issues during surprise inspections at other facilities.

"They were short-staffed prior to COVID, and they’ve been short-staffed during COVID, and and they’re short-staffed now," said a woman whose relative is at Universal Healthcare Lillington.

The facility has had two outbreaks. From May 1 to July 21, 17 staff members and 73 residents tested positive for coronavirus, and 19 of the residents died.

The relative, who didn’t want to be identified, said she wasn’t surprised when COVID-19 spread like wildfire at the facility.

"They did not address it in the very beginning. They spent more time trying to cover up that there was a COVID outbreak than to notify us," she said.

Universal Healthcare Lillington is now in the middle of a second outbreak that started Oct. 27. So far, it has affected 34 staff members and at least 31 residents, five of whom have died.

WRAL Investigates found the state conducted multiple surprise inspections at the facility during the pandemic and uncovered problems:

  • In July, the inspectors themselves weren’t screened at the front door, which was a requirement for all visitors.
  • In September, the facility was placed on immediate jeopardy for five violations. Most concerning among those was not having staff assigned to work only in the COVID-positive unit to prevent cross-contamination in healthy parts of the building.

The resident's relative said that finding wasn’t a surprise, noting that she tried to get it addressed months earlier.

"I reported that one nurse was seen on the COVID hall caring for my mother, and when the state went to investigate, it was turned up to not be substantiated," she said.

The woman also contacted state health officials and lawmakers in the early stages of the outbreak, even suggesting the North Carolina National Guard should be assigned to the home to help care for residents. One lawmaker’s office got involved, but extra help was never sent.

WRAL Investigates also found troubling surprise inspection results in other homes, including one of the homes with a fairly clean bill of health during the pandemic.

At Tower Rehabilitation and Nursing Center, the facility was cited after one resident’s son tried to give him a face shield for protection but the facility staff wouldn’t let him keep it, saying it wouldn’t be fair to other residents even though there was no policy on the use of face shields.

At Signature Healthcare in Roanoke Rapids, a nurse’s aide admitted to working for a week while feeling symptoms of COVID-19 before eventually testing positive. The facility responded by retraining staff about symptoms and when not to come to work. The infraction happened during an outbreak that infected 44 and killed eight residents.

While the most common infractions found during the surprise inspections included things like not properly wearing masks and not properly disposing of gowns and other protective gear, others were much more concerning. One nursing home in the mountains, for example, failed to test every resident after a nurse received a positive test in September. Within weeks, the facility had more than 70 cases, and 10 residents died.

Universal Healthcare Lillington and the other facilities didn't respond to WRAL Investigates' requests for comment.

The daughter WRAL Investigates spoke to was disappointed in her facility’s handing of the outbreak, as well as the state’s response.

"Our state needs to recognize we need to a better job in reviewing the facilities and these nursing homes," she said. "This is not a shocker, and this hasn’t happened overnight."

The inspections show how one slip-up, one oversight or a lack of training for staff could lead to more pain and suffering for residents and loved ones.

"Are we going to value the bottom line over these elderly lives?" the woman said. "There’s 24 people dead, and these were people that, but for COVID and but for being in this facility, they may still be alive."

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