Within two months of the opening of a Covington nursing home, state investigators cited it twice for serious violations of state regulations following one resident's death and another's stroke.
Investigators found that Providence Pavilion's failure to have an effective system in place to ensure that residents received medicines and lab tests ordered by doctors placed them "in imminent danger," according to a state citation.
On Feb. 26, Providence Pavilion received two Type A citations, the most serious given by the Cabinet for Health and Family Services' Inspector General, according to state documents.
The facility began accepting residents in early January in a refurbished building that once housed St. Elizabeth North Hospital.
A resident who died January 30 had been sent to a hospital emergency room on January 27 to treat "an open area" that would not stop bleeding, according to the citation.
After the resident returned to Providence that day, a doctor ordered that the patient should not receive a regular dose of Coumadin, a medication used to prevent blood clots.
The physician also ordered a test to monitor the resident's blood on January 28.
But staff at the facility did not transcribe the order and gave the resident the medication in spite of the doctor's order.
The physician told state officials that the nursing home staff should have withheld the medication and should have notified him on January 28 that they had no results of the blood tests.
When a staff member called the physician on January 29, the lab results showed life threatening bleeding levels, the citation said. The resident was found dead at 4 a.m. January 30.
In the second case that led to a citation, the resident's average blood pressure was 134/70 and average blood sugar was 255.
When the resident became became dizzy at 6:45 p.m. January 20, the blood pressure was found to be 228/108 and their blood sugar was 522.
The physician said the nursing home told him about the elevated blood sugar and he ordered a dose of insulin. But the physician told state officials that the nursing home staff never told him about the high blood pressure.
The physician said that had he known, he would have ordered that the resident be sent to the hospital.
Additionally, there is no documented evidence that the facility assessed the resident or monitored the blood pressure for the next two hours and 25 minutes after noticing the elevated blood pressure, the citation said.
At 12:45 a.m. January 21, the resident could not move the left hand, had a weak grasp, limp arm and difficulty moving the left leg.
The resident was taken to a hospital and diagnosed with a stroke with paralysis on the left side.
The facility had no formal orientation or competency evaluation for their nursing staff, which its policies called for, according to the citation. It was unable to provide evidence that it had developed and implemented a policy on notifying physicians. And, nurses had not been trained in regard to notifying physicians, the citation said.
The residents, the staff, and the physicians were not identified in state documents.
Cabinet spokeswoman Beth Fisher said facility officials immediately corrected the issues, even before state officials concluded their investigation. The nursing home doesn't face any further action, Fisher said.
Sue Schuman, a spokeswoman for Providence Pavilion, said that the facility is going "above and beyond" to meet requirements and has made changes to policies and procedures.
Schuman said the facility disputes some of the findings in the citations.
"There's a lot more to the story than what's on paper," she said.