LIBERTY, KY - A federal inspection at Liberty Care and Rehabilitation Center documented multiple safety violations that compromised medication management and infection control protocols, including a four-day delay in providing tuberculosis medication to a newly admitted resident.
Tuberculosis Medication Delays Compromise Treatment
The most concerning violation involved a resident admitted on June 7, 2024, with latent tuberculosis who was prescribed rifampin, a critical antibiotic for TB treatment. The medication was ordered to be administered daily between 7:00 AM and 11:00 AM, but the facility failed to ensure timely delivery from their pharmacy.
According to inspection records, the pharmacy's shipping manifest showed rifampin was not included in the June 7 delivery. The medication didn't arrive until June 10 at 8:15 PM - well after the scheduled administration time. As a result, the resident missed three consecutive days of treatment on June 8, 9, and 10.
The Staff Development/Infection Control nurse acknowledged the delay, stating "it would be important to ensure rifampin was administered as ordered for the resident's diagnosis of latent TB." Both the Director of Nursing and Administrator reported they were unaware of the pharmacy delay, highlighting communication gaps in medication management.
Rifampin is essential for treating latent tuberculosis because it prevents the infection from becoming active TB disease. Missing doses can reduce treatment effectiveness and potentially lead to drug resistance, making future treatment more difficult and less successful.
Medication Dosage Errors Following Supply Issues
Once the rifampin arrived, new problems emerged. The resident was prescribed two 300-milligram tablets daily but received only half the prescribed dose - one tablet instead of two - on June 11 and 12.
Federal inspectors observed the error during a medication pass on June 13, when a registered nurse administered only one tablet. A pill count revealed the medication container had four tablets missing instead of the expected six, confirming the underdosing pattern.
The Staff Development/Infection Control nurse acknowledged that incorrect dosing "might not be therapeutic for treatment of the resident's latent TB" and stated she would contact the physician about the medication error. Proper antibiotic dosing is crucial for TB treatment success and preventing bacterial resistance.
Widespread Infection Control Failures
The facility demonstrated systematic failures in infection prevention protocols across multiple areas of care. Staff repeatedly violated basic infection control principles that are designed to prevent disease transmission among vulnerable nursing home residents.
Improper Equipment Cleaning and Handling
Inspectors documented improper cleaning of medical equipment used by multiple residents. During medication rounds, a registered nurse failed to sanitize shared blood pressure cuffs and pulse oxygen monitors between residents, violating protocols designed to prevent cross-contamination.
The nurse acknowledged she should clean equipment between each use with a three-minute contact time for disinfection, but failed to follow these procedures during observed care.
Blood Glucose Monitoring Violations
Serious infection control breaches occurred during blood glucose testing. An agency nurse was observed handling a contaminated glucometer with bare hands after performing a fingerstick, placing the blood-contaminated device on a medication cart next to a water pitcher.
The nurse then disposed of a bloody test strip without wearing gloves and failed to perform hand hygiene afterward. When cleaning the glucometer, she used personal wet wipes instead of the required germicidal disinfecting wipes and didn't allow proper drying time before storage.
Proper glucometer cleaning requires removing all blood and bodily fluids, then disinfecting with appropriate wipes that remain wet for the required contact time. These protocols prevent transmission of bloodborne pathogens between residents.
Personal Protective Equipment Failures
Staff repeatedly failed to use personal protective equipment when caring for residents under isolation precautions. Multiple violations occurred with residents requiring contact precautions for shingles and enhanced barrier precautions for wounds.
One student nurse entered a shingles patient's room without donning required gown and gloves, then removed the patient's television remote from the room. She only noticed the contact precautions signage after exiting and failed to perform hand hygiene before putting on protective equipment for re-entry.
Food service staff also violated enhanced barrier precaution requirements, entering isolation rooms without protective equipment while delivering meals and snacks. These failures could facilitate disease transmission throughout the facility.
Hand Hygiene Compliance Issues
Basic hand hygiene - the most fundamental infection control measure - was inconsistently performed throughout the facility. Staff failed to sanitize hands between resident contacts during meal service and medical care.
Food service personnel were observed passing dinner trays to six consecutive residents without performing hand hygiene between deliveries. Facility policy requires hand sanitization after each tray delivery and handwashing every third tray.
Medical staff also failed hand hygiene protocols during blood glucose testing and when moving between residents during medication administration.
Medication Storage and Labeling Deficiencies
The facility failed to properly label opened insulin vials with opening dates, creating risks for medication safety. Inspectors found two opened insulin vials without date markings on the North Wing medication cart.
Proper dating of opened medications ensures staff can determine when products expire and need replacement. Insulin effectiveness decreases over time once opened, and using expired insulin can lead to inadequate blood sugar control.
Water Management Program Inadequacies
The facility's water management program failed to meet CDC guidelines for preventing Legionella growth. The plan lacked a comprehensive flow diagram showing water distribution throughout the building and didn't address potential Legionella growth sites like low-use sinks, showers, and ice machines.
Legionella bacteria can cause serious respiratory illness, particularly dangerous for elderly nursing home residents with compromised immune systems. Proper water management programs identify risk areas and establish monitoring protocols to prevent bacterial growth.
Catheter Care Safety Concerns
Improper catheter care practices created infection risks for residents with indwelling urinary catheters. Staff contaminated catheter drainage systems by allowing the drainage spigot to contact urinal surfaces during emptying procedures.
A student nurse emptied a catheter bag into an unlabeled urinal, touching the spigot to the urinal's interior surface. The urinal was then stored without proper labeling or protective bagging, violating infection control protocols designed to prevent urinary tract infections.
Regulatory Response and Facility Accountability
The violations received "minimal harm or potential for actual harm" classifications, but the cumulative effect of multiple infection control failures created significant risk for disease transmission. The facility's leadership acknowledged gaps in staff education and monitoring of safety protocols.
The Director of Nursing stated that both in-house and agency staff receive infection control training, but inspection findings revealed inconsistent compliance with established policies. The Administrator emphasized expectations for proper equipment cleaning and protective equipment use.
The inspection highlighted the critical importance of consistent medication management and infection control in nursing homes, where residents' age and medical conditions make them particularly vulnerable to treatment delays and infectious disease complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liberty Care and Rehabilitation Center from 2024-06-14 including all violations, facility responses, and corrective action plans.
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