COLUMBUS, GA - Federal inspectors cited Magnolia Manor of Columbus Nursing Center - East for multiple care violations including dangerous medication errors for a diabetic resident and inadequate infection control protocols.
Critical Medication Error During Surgery
The most serious violation involved a diabetic resident who was given insulin on June 10, 2024, despite explicit physician orders to withhold all diabetic medications on the day of a scheduled vascular procedure. The resident was undergoing an atherectomy, a procedure to remove arterial plaque buildup.
Hospital procedure instructions from the resident's cardiologist clearly stated to "hold insulin the day of the procedure." Facility nursing notes from June 7 documented pre-operative orders specifying "not give diabetic medications or insulin the day of the procedure."
Despite these documented orders, nursing staff administered both types of prescribed insulin to the resident on the surgery day - 6 units of Novolog insulin at 3:49 pm and 6:30 pm, plus 30 units of Lantus insulin at 12:00 pm. The resident had been transported to the surgical center at 6:29 am and returned at noon after the procedure.
When questioned by inspectors, the Director of Nursing acknowledged a "computer input error" in the medication system. The insulin hold order was programmed incorrectly to last only from midnight to 10 am, rather than the entire day as ordered.
This medication error created significant safety risks. Administering insulin before and after surgery can cause dangerous blood sugar fluctuations when patients are fasting and receiving IV fluids. Proper diabetes management during surgical procedures requires careful coordination between medical teams to prevent hypoglycemia or other complications.
Missing Blood Sugar Monitoring
Inspectors also found the facility failed to follow physician orders for comprehensive blood sugar monitoring. The diabetic resident had standing orders from December 18, 2023, requiring blood sugar checks before meals and at bedtime.
Review of medication records from December 2023 through June 2024 showed the facility consistently obtained morning, late morning, and afternoon blood sugar readings. However, the required bedtime blood sugar checks were never scheduled or performed until after inspectors questioned the practice on June 18, 2024.
The Director of Nursing admitted to inspectors on June 20, 2024, that "there was no evidence of the bedtime blood sugar reading being scheduled on the electronic medication record or done."
Regular blood sugar monitoring at multiple times throughout the day is essential for managing diabetes safely. Bedtime readings help detect overnight blood sugar patterns and guide insulin dosing decisions to prevent dangerous episodes while residents sleep.
COVID-19 Tracking Failures
Federal inspectors found significant gaps in the facility's infection control surveillance system. A resident who tested positive for COVID-19 on January 24, 2024, was never included in the facility's infection tracking logs, despite documented positive test results and care plan updates.
The facility's own COVID-19 response policy requires maintaining test results in resident medical records and keeping logs of all resident testing. Nursing notes clearly documented the resident's positive COVID-19 status, stable vital signs, and absence of symptoms.
The resident remained in her room with her roommate, who also tested positive for COVID-19, according to the Director of Nursing. However, when inspectors reviewed the facility's January 2024 infection tracking reports and COVID-19 specific logs, the resident was missing from both documents.
The Director of Nursing could not produce evidence of a COVID-19 testing sheet for the resident's positive test. This tracking failure compromises the facility's ability to monitor infection patterns, implement appropriate isolation measures, and report accurate data to health authorities.
Vaccination Documentation Problems
Inspectors identified three residents who consented to pneumonia vaccinations but never received them. The violations occurred between October 2022 and December 2023.
All three residents or their representatives signed informed consent forms agreeing to receive the pneumococcal vaccine. The facility's infection prevention policy requires offering vaccines upon admission and documenting whether residents receive immunizations.
Despite signed consent forms, medical records contained no evidence the vaccines were administered to any of the three residents. The Director of Nursing acknowledged being unable to find documentation that the pneumonia vaccines were given despite having valid consent.
Regulatory Response
The violations occurred during a complaint investigation completed June 27, 2024. All cited deficiencies were classified as causing "minimal harm or potential for actual harm" affecting few to some residents.
Federal regulations require nursing homes to provide treatment according to physician orders and maintain comprehensive infection control programs. The facility must submit correction plans addressing each violation to continue participating in Medicare and Medicaid programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Manor of Columbus Nursing Center - East from 2024-06-27 including all violations, facility responses, and corrective action plans.
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