SWANSEA, MA - Country Gardens Health and Rehabilitation Center was cited for 20 violations during a July 2024 inspection, including critical failures in medication monitoring, infection control, and staff training that put residents at risk.
Critical Medication Safety Failures Put Residents at Risk
Federal inspectors found serious deficiencies in how the facility monitored residents receiving high-risk medications, particularly blood thinners and diabetes medications that require careful supervision to prevent dangerous complications.
The facility failed to properly monitor three residents on anticoagulant medications, which are blood thinners used to prevent clotting. For two residents receiving Enoxaparin and Apixaban, staff did not have orders in place to monitor for adverse effects despite facility policy requiring such monitoring. These medications can cause serious bleeding complications, including internal hemorrhaging, drops in blood pressure, and dangerous blood clots if monitoring protocols are not followed.
Medical Significance of Anticoagulant Monitoring
Anticoagulants require vigilant monitoring because they alter the blood's ability to clot. Without proper oversight, residents can experience life-threatening bleeding episodes or, conversely, develop blood clots if the medication becomes ineffective. Signs that staff should monitor include unusual bruising, nosebleeds, blood in urine or stool, and changes in mental status that could indicate internal bleeding.
The facility's own policy clearly stated that care plans should alert staff to monitor for "bleeding and hemorrhage, fall in hematocrit or blood pressure, and thromboembolism." Yet when interviewed, nursing staff acknowledged that residents "should have had an order to monitor adverse consequences but did not."
A third resident with diabetes was also inadequately monitored while receiving multiple blood sugar-lowering medications, including insulin injections and oral medications. This resident required monitoring for hypoglycemia (dangerously low blood sugar), which can cause confusion, loss of consciousness, and potentially fatal complications if not promptly treated.
Dangerous Medication Error Compromises Post-Surgical Care
In a separate incident, a resident recovering from hip fracture surgery did not receive a prescribed blood thinner for an entire day, potentially increasing the risk of dangerous blood clots. The resident had undergone surgical repair of a right hip fracture and was prescribed Enoxaparin to prevent deep vein thrombosis, a serious complication where blood clots form in deep veins.
According to medical literature, interruption of anticoagulant therapy can significantly increase the risk of blood clots during and after surgery. When the medication was not available from the pharmacy, the nurse documented it as "not available" but failed to notify the physician or access emergency medication supplies that were available on-site.
Clinical Context of Post-Surgical Blood Clot Prevention
After orthopedic surgery, particularly hip procedures, patients face elevated risk of developing blood clots due to immobility and surgical trauma. Blood thinners are considered essential preventive care during this vulnerable period. Missing even a single dose can allow the blood's clotting mechanism to return toward normal levels, potentially allowing dangerous clots to form.
The facility had emergency medication kits containing the needed drug, but staff failed to utilize these resources. As one unit manager noted, the nurse "should have notified the Physician or Nurse Practitioner and accessed the e-kit to obtain and administer enoxaparin, but did not."
Widespread Infection Control Failures Observed
Inspectors documented multiple instances where staff failed to follow proper infection control protocols, particularly for residents requiring Enhanced Barrier Precautions (EBP) and Contact Precautions. These protocols are designed to prevent the spread of multidrug-resistant organisms and other infectious agents.
The violations included staff failing to wear required gowns and gloves when providing care to residents with central lines, urinary catheters, and wounds. In one case, a nurse was observed handling IV equipment and administering medication through a central line without wearing a gown, despite clear signage indicating enhanced precautions were required.
Infection Control Standards and Risk Mitigation
Enhanced Barrier Precautions represent an evidence-based approach to preventing transmission of dangerous organisms in nursing homes. These protocols require staff to wear gowns and gloves during high-contact activities such as bathing, dressing, changing linens, and providing wound care for residents with indwelling medical devices or chronic wounds.
Failure to follow these protocols can lead to serious infections, including antibiotic-resistant organisms that are difficult to treat. Central lines, like the PICC line mentioned in the violations, provide direct access to the bloodstream and require meticulous infection control to prevent life-threatening bloodstream infections.
Staff were also observed failing to perform basic hygiene measures, such as cleaning tables between activities and meals, and not providing hand hygiene for residents before eating. One resident specifically requested that their hands be cleaned before meals, highlighting awareness of the issue.
Systematic Training Deficiencies Compromise Care Quality
Perhaps most concerning was the facility's failure to provide mandatory training to direct care staff. Eight staff members, including nurses and certified nursing assistants, lacked required training in critical areas including effective communication, resident rights, infection control, and behavioral health.
The facility's Staff Development Coordinator, who had been in the role for only three months, acknowledged the training gaps and stated she was "trying to catch up on the mandatory trainings." However, no additional training records were provided to inspectors by the end of the survey.
Training Requirements and Patient Safety Connection
Mandatory training in nursing homes serves as a fundamental safeguard for resident safety and quality of care. Training in infection control helps prevent healthcare-associated infections, while education on medication management reduces the risk of adverse drug events. Communication training ensures that critical information about resident conditions is properly conveyed between shifts and disciplines.
The absence of these training programs suggests systematic gaps in the facility's ability to provide safe, quality care. Without proper education, staff may not recognize warning signs of medical emergencies, properly implement infection control measures, or understand their legal and ethical obligations to residents.
Additional Issues Identified
The inspection also revealed problems with medication storage, including loose pills left in medication carts, unlabeled inhaler devices, and controlled substances not properly secured due to broken locks. Food safety violations were found in unit kitchenettes, with expired thickened beverages, improperly labeled items, and unsanitary conditions that could lead to foodborne illness.
Medical record keeping was also deficient, with staff failing to complete required weekly skin assessments for three residents despite signing off that the assessments were completed. Accurate documentation is essential for tracking changes in resident conditions and ensuring continuity of care.
The facility's Quality Assurance committee was found to be non-compliant, with the infection preventionist failing to attend the last two quarterly meetings. This oversight role is crucial for identifying and addressing systematic issues before they impact resident care.
These violations represent significant departures from accepted standards of nursing home care and highlight the need for immediate corrective action to ensure resident safety and well-being.
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.
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