EAST LONGMEADOW, MA - A federal inspection at Care One at Redstone revealed systematic lapses in medication management, care planning, and clinical oversight that placed residents at risk for inadequate pain control and missing essential healthcare services.
Medication Management Failures Placed Residents at Risk
Federal surveyors documented multiple instances where Care One at Redstone failed to provide appropriate medication management for residents experiencing severe pain. In one case, a resident admitted in April 2024 following surgery for a fractured kneecap reported pain rated at 8 out of 10—a level considered severe on the standardized pain scale.
Despite having a physician's order for morphine sulfate to address severe pain, the prescribed medication was not available from the pharmacy when the resident needed it. Rather than contacting the on-call medical provider to obtain an emergency order for equivalent pain medication from the facility's emergency supply kit, nursing staff instead administered Ativan, an anti-anxiety medication not indicated for pain management.
The resident experienced severe pain for approximately 15 hours before receiving the appropriate pain medication. According to professional nursing standards, when scheduled pain medication is unavailable and a resident reports severe pain, facilities must contact medical providers immediately to obtain alternative orders. This ensures continuity of pain management and prevents the complications that can arise from sudden interruption of opioid therapy, including withdrawal symptoms and decreased effectiveness of pain control.
The risks extend beyond immediate discomfort. When patients who regularly use narcotic pain medications experience gaps in administration, their pain can become progressively harder to manage effectively. The body's pain receptors may become more sensitized during the interruption period, requiring higher doses or different medication combinations to achieve adequate relief.
Chronic Medication Unavailability Went Unaddressed
Inspection records revealed an even more concerning pattern involving a long-term resident with dementia, depression, and behavioral disturbances. This resident had been prescribed ABH gel—a topical combination medication containing Ativan, Benadryl, and Haldol used to manage anxiety related to major depressive disorder.
The medication administration records showed the gel was unavailable from the pharmacy for 24 consecutive days in January 2024. During this period, nursing staff documented the medication as "unavailable," "awaiting delivery," or "on order" 47 times across morning and evening doses. Despite facility policy requiring notification of the physician when medications remain unavailable, surveyors found no evidence that medical providers were contacted to obtain alternative medication orders.
The resident's clinical record included specific care plans addressing verbal and physical agitation, combativeness with staff, episodes of refusing care and medications, and behavioral management needs. The prolonged absence of prescribed behavioral health medication created potential for symptom escalation and increased distress for a resident already experiencing significant mental health challenges.
Professional standards require facilities to make every effort to ensure medications are available to meet resident needs. When medications cannot be obtained, nursing staff must notify the attending physician to discuss circumstances, expected availability, and alternative therapies. If unable to reach the attending physician, nurses should contact the nursing supervisor and facility medical director for orders and direction.
Wrong Medications Administered Despite Safety Protocols
The facility's medication management problems extended to administration errors involving high-alert medications. Two separate nurses on different occasions administered the wrong formulation of morphine to a resident with multiple severe pressure ulcers and bone infection.
In both instances, nurses administered morphine sulfate extended-release tablets instead of the ordered immediate-release formulations. Extended-release medications deliver medication slowly over many hours, while immediate-release versions work more quickly for shorter durations. This distinction is critical for pain management—extended-release formulations provide steady baseline pain control, while immediate-release versions address breakthrough pain or pain associated with specific procedures like dressing changes.
Opioid medications are classified as high-alert drugs in healthcare settings due to their potential to cause serious harm if administered incorrectly. Professional nursing standards recommend independent verification by a second nurse before administering these medications. The surveyor's interview with one of the nurses involved revealed concerning gaps in understanding, as the nurse could not identify steps that should have been taken to prevent recurrence of the error.
Care Plan Meetings Failed to Include Residents
Federal regulations require nursing facilities to provide residents and their representatives the opportunity to participate in developing and reviewing their care plans. Facilities must hold care plan meetings at admission and at least quarterly thereafter to ensure the plan remains current and reflects resident needs and preferences.
Surveyors found that one resident admitted in January 2024 received no care plan meetings since admission—missing both the required admission meeting and the subsequent quarterly review. For another long-term resident, the facility failed to conduct required quarterly meetings during two separate gaps: between November 2022 and May 2023, and again between May 2023 and November 2023.
The care planning process serves multiple essential functions. It provides residents and families opportunity to voice preferences, concerns, and goals for care. It allows the interdisciplinary team to coordinate their approaches and ensure all disciplines work toward common objectives. Regular reviews ensure the care plan evolves as resident conditions and needs change.
When facilities fail to conduct required care plan meetings, residents lose their voice in decisions affecting their daily lives and medical care. Family members miss opportunities to provide important information about their loved one's preferences, history, and responses to interventions. The interdisciplinary team loses the structured forum for comprehensive review and coordination.
PICC Line Management Deficiencies Created Safety Risks
A resident receiving intravenous antibiotic therapy through a peripherally inserted central catheter (PICC line) did not receive required monitoring and care. The physician ordered weekly dressing changes and measurements of the external catheter length—a critical safety measure to detect if the catheter has migrated out of proper position.
Facility records showed the PICC dressing change scheduled for May 28, 2024 was not performed, leaving the documentation blank. When the dressing was finally changed on May 30, the external catheter measurement was 2 centimeters—a change from the baseline of 0 centimeters established at insertion. By June 4, the external length had increased to 11 centimeters.
These measurement changes indicated the catheter was migrating outward from its insertion site. Professional standards require nurses to report such changes to physicians immediately, as catheter migration can result in infiltration—where medication enters surrounding tissues instead of the bloodstream—or increase risk for blood clots. Surveyors found no evidence that physicians were notified of these measurement changes.
The resident reported having to ask staff to change the dressing because it had not been done since admission and was falling off. During observation, surveyors noted the dressing had been changed at 12:15 A.M. but lacked the required date documentation.
Additional Issues Identified
Federal inspectors documented several other deficiencies during the June 2024 survey:
Screening and Assessment Gaps: The facility failed to accurately complete required mental health screening for a resident with bipolar disorder who had received behavioral health services in the community. The screening errors resulted in the resident not receiving a required Level II evaluation to determine needs for specialized mental health services.
Pharmacist Recommendations Ignored: When the consultant pharmacist recommended monitoring measures for a resident on antipsychotic medication—including movement disorder screening, orthostatic blood pressure checks, and psychiatric evaluation—the facility took between 1.5 and 3.5 months to implement the recommendations despite policy requiring monthly response.
Hearing Services Denied: A resident who requested hearing services upon admission in 2021 and expressed concerns about difficulty hearing in 2024 never received audiology evaluation, despite being enrolled with the mobile contracted provider.
Laboratory Testing Overlooked: A resident prescribed antipsychotic medication with a history of breast cancer did not receive ordered annual electrocardiograms since 2019, annual mammograms since 2019, or required thyroid function tests since 2023.
Trauma-Informed Care Absent: A resident with post-traumatic stress disorder received no assessment to identify trauma triggers or care plan to address the diagnosis, contrary to facility policy requiring universal trauma screening and individualized care planning.
Food Service Sanitation: Kitchen staff prepared and served food without required beard restraints, and dietary aides handled ready-to-eat foods with gloved hands after touching boxes, cart handles, and storage room items without changing gloves or performing hand hygiene between tasks.
Medication Storage: Refrigerators storing medications on two units contained reddish-brown substances dripping down interior walls onto shelves where medications were kept, creating contamination risks.
The inspection was conducted June 6, 2024, by the Massachusetts Department of Public Health on behalf of the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care One At Redstone from 2024-06-06 including all violations, facility responses, and corrective action plans.
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