NC lawmakers question DHHS after report reveals dire conditions at Thomasville nursing home where two died

The joint oversight panel for the North Carolina Department of Health and Human Services heard a report from Emery Milliken, who is the state's top regulator for adult care facilities. The report detailed the agency's investigation of the event, the subject of a 160-page report released to the public last Friday.

According to the report, due to a winter storm, only three people were working at the Pine Ridge Health and Rehabilitation Center on Sunday, Jan. 16, 2022. The three staff — one nurse and two nurse aides — were attempting to care for 98 residents.

"Typically, there are 13 to 15 individuals there [to care] for the 98," Milliken said.

It includes medication aides, three nurses and eight to 10 nurse aides, according to Milliken.

The report said that there were also no dietary staff that came into work that day, which means that nurses were rapidly trying to prepare meals while also caring for the patients.

"A number of those individuals are in the bed until you come to get them out of the bed, and they're incontinent of bowel and bladder," she added. "I mean, a lot of these residents are totally dependent on care from the staff."

Milliken said residents at the facility had begun calling 911 to ask for help.

"These 911 calls reported the caller needed help, that she hadn't seen staff for hours, couldn't reach staff, that she was wet, she was hungry, she had not had supper," Milliken told the committee.

When police responded to the facility, they found a chaotic scene. Residents were wandering, crying and calling for help. Some were sitting in their own urine and waste. They had not had their medications for the day, and for meals, only breakfast.

According to the report, police said that the smell of feces and urine was overwhelming. Officers also saw what appeared to blood in the hallways.

Two residents were found to have died, and two others in critical condition were taken to a hospital.

Police called in EMS and fire personnel to help, and notified Davidson County's social services director, who — in turn — notified the state Sunday night. They also called in medical staff from the surrounding area to assist.

The report said that "neglecting to meet the needs of the residents had the high likelihood of causing severe psychological and physical harm to all 98 residents."

The report claims the nursing home did not properly prepare for snow and ice that day, and ignored all regulations from the state to do so. The administrator at the time was fired after ignoring the nursing home's inclement weather plan and failing to review plans for an emergency.

"She did not supply an explanation as to how come she had not alerted him or other corporate members the situation regarding the lack of staffing," the DHHS report says.

The administrators did not try to call in more staff to help during the storm and did not set up a clear schedule for that day, according to the report.

The three staff members at the facility stayed for hours trying to keep patients alive, the report details. The only nurse there became so overwhelmed she had a panic attack and was almost sent to the hospital.

“The police officer then described the nurse, 'almost broke down into tears' and stated she was by herself, she did not know where all of the other staff were, she had been at the facility for 16 hours, she had conversations with the director of nursing and was told by there was nothing she could do to help her but at midnight to find a room to lay down and get some rest," the report said.

Committee members questioned how the situation could have gotten so bad so quickly. The facility was last inspected in June 2021. At the time, inspectors verified that the facility had an updated emergency plan in place as required by state and federal law for severe weather events.

However, Milliken said facility management changed in August. The new administrator did not know about the emergency plan, and did not make any preparations for the weather event.

"You can't read that report and not feel a real sense of sadness for both what happened to the residents and for those three staff who were trying so hard to serve the needs of 98," she said. "I think it was truly a traumatic incident for both."

Milliken said her office, the Division of Health Service Regulation, spent more than 500 hours conducting its investigation, 108 of them on site at the facility. The investigation found eight of the highest-level violations, those that put residents at immediate risk of serious harm or death.

The findings were sent to the federal Centers for Medicaid Services, which has taken punitive action against the facility owners, she said. She said the management has taken action to correct the immediate dangers and is implementing changes to avoid a repeat.

"DHSR has been asked to provide a copy of our report to the police and the SBI. And we will be sending a letter to the North Carolina Board of Examiners for the nursing home administration regarding the incident as well," she told lawmakers.

"This is the most vulnerable population, and I'm very concerned," said Rep. Steve Jarvis, R-Davidson. "You know, what if that was my mother? What if it was your mother, your father? We need to have things in place."

Rep. Gale Adcock, D-Wake, asked what state regulators are doing to try to prevent a similar event in the future.

"Just prior to this incident, we had approved a grant for an entity to provide training to nursing homes on the emergency preparedness requirements, what they needed to do, best practices. And that training actually was just Thursday and Friday of this past week," Milliken responded, adding that more than 700 staff members had taken the training.