SNELLVILLE, GA - Cambridge Post Acute Care Center received multiple citations during a July 2024 state inspection for systematic failures in medication administration, infection control protocols, and antibiotic stewardship that potentially compromised resident safety and health outcomes.
Critical Medication Administration Failures
The facility's medication management system showed significant deficiencies affecting diabetic residents' insulin administration and general medication delivery. Inspectors found that three of five reviewed diabetic residents experienced serious medication errors that could have resulted in dangerous blood sugar fluctuations.
One resident with chronic obstructive pulmonary disease missed 20 doses of his inhaler medication over two months, while another diabetic resident had 16 documented instances where insulin was not administered despite blood sugar readings that clearly required treatment according to physician orders. In one case, a resident's blood sugar reached 363 mg/dL - a dangerously high level - but no insulin was given, with staff incorrectly documenting the blood sugar as "within parameters."
The insulin administration problems extended beyond missed doses to include systematic documentation errors. Records showed multiple instances where blood sugar readings differed between monitoring devices and medication charts, and insulin doses were either omitted entirely or administered based on incorrect readings. For diabetic residents, this pattern of errors creates significant health risks.
When blood sugar levels remain uncontrolled, residents face both immediate and long-term consequences. Acute complications can include diabetic ketoacidosis, a life-threatening condition requiring emergency intervention. Chronically elevated blood sugar levels damage blood vessels and organs, increasing risks of heart disease, kidney failure, and vision problems. Conversely, if insulin is given inappropriately, residents could experience dangerous drops in blood sugar leading to confusion, seizures, or loss of consciousness.
During a resident council meeting, one affected resident stated: "They run out of my medications. They don't care if they are missing pills." Another resident reported: "It takes two to three days to get medications when they reorder."
The facility's own Nurse Practitioner acknowledged the problem, telling inspectors: "Yes, I am sorry to say it is true" when asked about medications not being administered on time.
Expired Medication Storage Violations
Inspectors discovered expired insulin vials on medication carts that had been used to treat residents. On one cart, they found a vial of Lantus insulin that had been open for more than 28 days - beyond its safe usage period. On another cart, a Novolog insulin vial lacked any opening date, making it impossible to determine when the medication expired.
Insulin effectiveness decreases significantly after expiration, particularly once opened. Most insulin formulations remain potent for only 28 days after opening when stored properly. Using expired insulin can result in poor blood sugar control, as the medication may not work as intended, putting diabetic residents at risk for the same complications associated with missed doses.
The facility's consulting pharmacist revealed this was "an ongoing problem at this facility" and confirmed he conducts monthly cart monitoring specifically to check for expired medications.
Infection Control Protocol Breakdowns
The facility failed to properly implement enhanced barrier precautions and transmission-based precautions for residents with infections or drug-resistant organisms. Staff were observed providing wound care without required protective equipment, and proper signage alerting staff to infection control requirements was missing or improperly placed.
One resident with multiple pressure sores required enhanced barrier precautions during high-contact care activities like wound treatment, bathing, and dressing changes. However, a nurse was observed providing wound care without wearing the required gown, and the facility's infection control signage was found on the floor behind the door rather than in a visible location.
Another resident with MRSA (methicillin-resistant Staphylococcus aureus) was not placed on proper transmission-based precautions until seven days after admission, despite hospital discharge records indicating the infection. The resident confirmed that "staff started wearing gowns and gloves yesterday" - a week after his arrival.
Proper infection control protocols serve as critical barriers preventing the spread of dangerous, antibiotic-resistant organisms between residents. MRSA and other drug-resistant bacteria can cause serious infections in vulnerable nursing home populations, potentially leading to pneumonia, bloodstream infections, or surgical site infections that are difficult to treat.
Antibiotic Stewardship Deficiencies
The facility lacked proper protocols for monitoring antibiotic use and determining clinical indications for treatment. Inspectors found no evidence that staff used the McGeer criteria - established clinical standards for diagnosing infections in long-term care settings - when prescribing antibiotics for urinary tract infections.
The facility's Infection Control Preventionist admitted to having no training in infection surveillance and stated: "I don't know anything about that" when asked about documentation requirements for antibiotic prescribing. This represents a significant gap in the facility's ability to prevent antibiotic resistance and ensure appropriate treatment decisions.
Proper antibiotic stewardship helps prevent the development of drug-resistant organisms and ensures residents receive appropriate treatment. Without systematic monitoring, facilities risk both under-treatment of serious infections and over-treatment that contributes to antibiotic resistance.
Additional Issues Identified
Inspectors also cited the facility for inadequate qualification of the infection control preventionist, who had not received updated training since 2022 despite being responsible for overseeing complex infection prevention programs. The facility Administrator acknowledged awareness of some issues but stated not knowing "the extent" of the problems.
These violations highlight systematic breakdowns in fundamental nursing home operations that directly impact resident health and safety. The combination of medication errors, infection control failures, and inadequate oversight creates multiple pathways for serious adverse health outcomes in a vulnerable population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cambridge Post Acute Care Center from 2024-07-09 including all violations, facility responses, and corrective action plans.
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