Rehabilitation Center of South Georgia: Medication Errors - GA

The July 4 inspection revealed systematic breakdowns across multiple departments at the 119-bed facility. Federal inspectors found staff failed to conduct required background checks on the administrator, director of nursing, and a certified nursing assistant who had worked there for over a decade.

Human Resources confirmed there were no employment reference checks for the three employees. The HR representative told inspectors a previous HR employee "had not completed references on employees," which she discovered during an employee file audit.

The administrator, hired in October 2023, told inspectors her expectation was for references to be completed prior to hire. But her own personnel file contained no reference checks, violating the facility's abuse prevention policy requiring thorough investigation of employment histories.

Licensed Practical Nurse 6 made two medication errors while inspectors watched her prepare medications for Resident 77, a severely cognitively impaired patient with dementia. The nurse crushed an enteric-coated aspirin that was specifically designed not to be crushed, potentially reducing the medication's effectiveness.

"I gave the wrong aspirin. It should have been the one you can crush," the nurse told inspectors after the observation.

The same nurse also pre-documented that the resident refused Colace, a laxative, without asking the resident first. "I knew that [R77] always refused the Colace, so I went ahead and documented that [R77] refused to take the Colace," she explained.

When asked when nurses should document medication refusals, the nurse admitted: "I guess I should have asked her before I documented that she had refused to take the Colace."

Two medication errors out of 27 opportunities observed resulted in the 7.41 percent error rate, well above the federal maximum of five percent.

Medication security problems extended beyond preparation errors. Another licensed practical nurse left her medication cart unlocked while Resident 79, a patient with diabetes and bipolar disorder, sat directly beside it in the hallway.

The nurse walked into a nearby room to ask another resident about medication preferences, leaving both the unlocked cart and a cup of prepared medications on top unattended. Resident 79 had access to both the cart drawers and the medication cup.

When inspectors asked the nurse if she could see the medication cart from inside the doorway, she confirmed she could not see either the cart or the medications left on top.

"The cart should always be locked when you are not with it," another nurse told inspectors.

The facility also failed to maintain adequate medication supplies. When Licensed Practical Nurse 6 tried to administer a rivastigmine patch to Resident 9, a patient with Alzheimer's disease and dementia, she discovered the facility had run out.

"The medication was never ordered, and I do not have a patch to replace the one that I removed," she told inspectors during the medication observation.

The corporate nurse confirmed medications should be reordered when supplies drop to one or two patches remaining.

Investigation failures compounded safety concerns in the memory care unit. The facility failed to conduct thorough investigations of resident-to-resident incidents involving four cognitively impaired residents, despite policy requiring written witness statements.

Licensed Practical Nurse 1 witnessed an incident among three residents but told inspectors: "I was not interviewed by the Administrator." She said she only documented what she witnessed in clinical records.

The administrator admitted she "could not locate any interviews conducted with witnesses/staff for any of the resident-to-resident incident files," despite stating she would have interviewed witnesses and collected statements.

The memory care unit suffered from severe neglect of activity programming. Inspectors observed residents with dementia "lined up against two walls which faced each other" with minimal staff engagement during multiple observations.

During one observation, residents sat facing the center of the room while a television played the Hallmark channel. Four residents were sleeping in their chairs. Staff had no supplies for engagement activities like puzzles or crafts appropriate for cognitively impaired residents.

The activity director, in her position for five months, admitted she had not implemented weekend activities for the memory care unit and was "attempting to implement individual activities for the five residents but had only focused on the residents outside of the memory care unit."

One resident's family member complained during a phone interview: "When I visit [R13] during mealtimes her food is always cold."

Temperature checks confirmed the family's concerns. Food temperatures dropped dramatically between kitchen preparation and delivery to residents. Beef tips measured 200 degrees when prepared but only 100 degrees when served. Mashed potatoes dropped from 166 degrees to 130 degrees. Lima beans fell from 198 degrees to 104 degrees.

The dietary manager confirmed the served food items were "below acceptable levels using a reasonable person standard and were considered cold and in need of reheating."

Fall prevention measures failed for two high-risk residents. Resident 43, who had a history of rolling off her bed, was supposed to have her bed in the lowest position according to her care plan. Inspectors observed the bed in an elevated position during four separate visits over two days.

Resident 84's fall mat was supposed to be placed on the right side of his bed but was consistently found at the foot of the bed with a wheelchair parked on top of it.

"The fall mat should be on the right side of the bed, and it is not in the right place right now," one nursing assistant confirmed during the inspection.

Infection control violations put residents at additional risk. Staff failed to follow contact precautions for a resident with urinary tract infection caused by antibiotic-resistant bacteria. A housekeeper entered the isolation room without protective equipment and touched the resident's linens.

During wound care, a licensed practical nurse failed to use proper sterile technique, placed dirty bandages on the bed instead of in a disposal bag, and used the same gloves throughout the procedure without changing them.

A nurse handling medications for a cognitively impaired resident placed pills on her notepad before picking them up with bare hands, violating medication handling policies.

The facility's antibiotic monitoring program failed to track a resident's repeated urinary tract infections and inappropriate antibiotic treatments. Resident 63 received six courses of antibiotics over seven months, including one antibiotic that was not effective against the identified bacteria.

The infection preventionist admitted: "We missed the big picture. We did not see the timeline of all the catheterizations and antibiotics. Every time a straight catheterization is completed, it is a possibility for an infection. We missed the wrong antibiotic administered and we must make changes."

Garbage disposal violations rounded out the facility's problems. Two of three dumpsters behind the kitchen were found with side doors pushed back and left open, exposing trash and potentially attracting pests.

The dietary manager acknowledged: "The dumpsters should be closed, others use the dumpsters but it's our responsibility to keep them closed."

The administrator, new to her position, told inspectors she was "aware the current Activity Director was attempting to bring activities to the memory care unit and stated she had identified the lack of activities on the secured unit last week."

No performance improvement plan addressed the activity deficiencies at the time of inspection.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Rehabilitation Center of South Georgia from 2024-07-04 including all violations, facility responses, and corrective action plans.

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