Country Gardens: Nurses Lacked IV Training - MA

The nursing staff, including the director of nursing and a unit manager, provided care to a resident with endocarditis who required IV antibiotics through a PICC line inserted directly into a major vein near the heart. The facility's own policy required all licensed nursing staff to complete IV medication administration competencies, but inspectors could find no evidence that nine of the staff members caring for the resident had received proper training.

The resident was admitted in May 2024 with a serious heart infection and had a double-lumen PICC line placed in the left basilic vein for six weeks of intensive antibiotic treatment. The catheter required precise monitoring, including measuring its external length with every dressing change to ensure it hadn't migrated or become dislodged.

But nurses repeatedly failed to follow the physician's order to measure the catheter length during dressing changes performed on June 6, 12, 19, and 26. The Staff Development Coordinator told inspectors she could find no documentation that the external length had been measured since the resident's admission.

"When she started in March 2024, she realized there was a need for staff education and competencies to be done," the inspection report stated. The coordinator provided a sign-in sheet showing PICC line education for 16 nurses on March 18, but only four of those nurses actually provided care to the resident requiring the specialized treatment.

The coordinator admitted she had no system in place to track whether nurses providing IV care had completed required training and competencies.

The facility's assessment acknowledged it provided medication administration through peripheral and central IV lines and stated all licensed nursing staff should complete IV medication administration competencies. The resident received multiple daily doses of ampicillin and ceftriaxone through the PICC line, medications that required careful administration and monitoring.

A separate violation involved a resident who brought a CPAP machine from home to treat sleep apnea but used it without any physician's orders. The cognitively intact resident told inspectors he managed the CPAP himself and that nurses would fill the water reservoir and turn the machine on for him.

The facility's own CPAP policy required physician orders specifying pressure levels, oxygen flow rates, cleaning schedules, and when to apply and remove the mask. Multiple nursing staff members, including the unit manager and director of nursing, acknowledged the resident should have orders for the CPAP but didn't.

On July 1, inspectors observed the resident in bed wearing the CPAP machine that had operated without medical supervision for months.

A third violation centered on staff training for behavioral health needs. A resident with dementia, anxiety disorder, major depression, and bipolar disorder required specialized care approaches, but key staff members lacked proper training.

The resident's care plan documented challenging behaviors including "calling out for attention repeatedly," wandering into other residents' rooms while undressed, and using a cane as a weapon during aggressive episodes. On May 18, the resident became physically and verbally abusive, threatening staff with the cane until nurses called 911 to transport him to the hospital for psychiatric evaluation.

When inspectors observed the resident on June 24, he was standing in his room crying and unable to answer questions. A nursing assistant who entered to help stated "he/she was always like this" and assisted the resident back to bed.

The facility's assessment recognized it served residents with "impaired cognition, depression, anxiety disorder, schizophrenia, bipolar disorder, dementia" and stated the need to "identify and implement interventions to help support individuals" with psychiatric conditions.

But education records showed the nursing assistant and the nurse who handled the May 18 crisis had received no training on caring for residents with mental and psychosocial disorders. The Staff Development Coordinator confirmed all education files had been provided to inspectors and that the facility used only paper-based training programs.

The Chief Nursing Officer acknowledged that mandatory training on behavioral health policies and procedures should be completed upon hire and annually thereafter.

The violations reflect broader staffing competency issues at the 120-bed facility. Country Gardens' own facility assessment stated the need to "develop skill set/competency of associates" to achieve strong clinical outcomes for residents with "multiple co-morbidities requiring a well-rounded clinical team."

Federal inspectors classified all three violations as causing minimal harm or potential for actual harm. The CPAP violation affected few residents, while the IV training deficiency and behavioral health training gaps affected some residents.

The inspection occurred on July 1, 2024, as part of routine federal oversight of nursing home care standards. Country Gardens must submit a plan of correction addressing how it will ensure proper physician orders for medical equipment, verify nursing competencies for specialized care, and provide adequate behavioral health training for staff.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Country Gardens Health and Rehabilitation Center from 2024-07-01 including all violations, facility responses, and corrective action plans.

Additional Resources

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