GARRISON, ND - Federal inspectors found serious lapses in safety protocols at Benedictine Living Center of Garrison during a July 2024 inspection, including failure to report multiple resident-to-resident assaults and dangerous medication errors involving diabetic residents.
Unreported Assault Incidents Raise Safety Concerns
The most significant violation involved the facility's failure to report resident-to-resident assaults to the State Survey Agency as required by federal regulations. Inspectors found multiple documented incidents where residents physically attacked other residents, yet none were reported to state authorities.
In one incident on June 13, 2024, a resident with psychotic disorder and Alzheimer's disease "started kicking [another resident] and punch him like 3-4 times" while he was checking oxygen tubing that had become tangled around her wheelchair. Documentation showed the attacking resident had known dementia and could not recall the incident.
A second case involved a resident with bipolar disorder who admitted to slapping another resident on the morning of June 8, 2024. According to facility notes, she "verbalized that [the victim] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him." The resident stated she couldn't remember if she struck him once or twice.
Additional incidents included a July 15, 2024 altercation where a male resident became upset and slapped a female resident across the left side of her face after she "put her fists up towards [his] face." Staff documented that they moved the residents away from each other and redirected the aggressor to another area.
Federal regulations require nursing homes to report incidents of resident abuse to state authorities within 2 hours if the event involves abuse or serious bodily injury, or within 24 hours for other incidents. The facility's own policy acknowledged this requirement, defining resident-to-resident altercations as incidents where "a resident willfully inflicts injury upon another resident."
When questioned during the inspection, an administrative staff member confirmed that none of these resident-to-resident incidents had been reported to the State Survey Agency, placing all residents at risk for continued abuse.
Critical Insulin Administration Errors
Inspectors observed dangerous medication errors involving rapid-acting insulin administration that could have resulted in life-threatening hypoglycemic reactions. Three residents received their insulin at improper times, violating manufacturer safety guidelines designed to prevent dangerous drops in blood sugar.
Rapid-acting insulins like Humalog and NovoLog are specifically formulated to work quickly with meals. Humalog must be administered within 15 minutes before a meal or immediately after eating, while NovoLog requires a meal within 5 to 10 minutes of injection. These timing requirements are critical because the insulin begins lowering blood sugar immediately, and without food to provide glucose, residents can experience dangerous hypoglycemia.
During observations, inspectors documented several timing violations:
- A resident received 20 units of NovoLog insulin at 3:38 p.m. but didn't receive dinner until 4:50 p.m., creating a 72-minute gap that far exceeded safe parameters - Another resident was given 20 units of Humalog insulin at 4:04 p.m. and received the evening meal at 4:33 p.m., a 29-minute delay that violated manufacturer guidelines - A third resident received 2 units of NovoLog insulin at 8:43 a.m. but didn't get breakfast until 9:11 a.m., a 28-minute interval beyond recommended timing
These timing errors are particularly dangerous for nursing home residents, who may have compromised awareness of hypoglycemic symptoms due to dementia or other cognitive conditions. Low blood sugar can cause confusion, dizziness, weakness, and in severe cases, seizures or loss of consciousness.
Medication Preparation Errors Compound Safety Issues
Beyond timing problems, inspectors found that nursing staff were improperly preparing insulin injections, creating additional medication errors. Two nurses were observed failing to follow manufacturer instructions for priming insulin pens before use.
One nurse prepared insulin with the safety cap still attached while attempting to prime the pen, preventing proper medication flow. Another nurse held the insulin pen pointing downward during priming instead of upward as required by manufacturer instructions. These preparation errors can result in inaccurate dosing, as the insulin pen may not deliver the intended amount of medication.
The inspection revealed a 12.5 percent medication error rate based on four errors occurring during administration of 32 medications. Federal regulations require nursing homes to maintain medication error rates below 5 percent, meaning this facility's rate was more than double the acceptable threshold.
Medical Context and Risk Assessment
Proper insulin administration is fundamental to diabetes management in nursing homes, where residents often have complex medical conditions and limited ability to recognize or communicate symptoms of blood sugar problems. The timing requirements for rapid-acting insulin exist because these medications begin working within 15 minutes and peak at 30-90 minutes after injection.
When insulin is given too far in advance of meals, residents face the risk of hypoglycemia, which can be particularly dangerous for elderly individuals. Symptoms may include sweating, trembling, confusion, and irritability, but nursing home residents with dementia may not be able to communicate these warning signs effectively.
The failure to report resident-to-resident incidents creates ongoing safety risks beyond the immediate physical harm. These incidents often indicate inadequate supervision, insufficient behavior management programs, or inappropriate resident placement. Without proper reporting and investigation, patterns of aggressive behavior cannot be identified and addressed, leaving vulnerable residents at continued risk.
Residents with cognitive impairments, psychiatric conditions, or dementia require specialized care plans and supervision to prevent aggressive episodes. The documented incidents suggest systemic problems with behavior management and resident monitoring that could affect facility-wide safety.
Industry Standards and Regulatory Requirements
Federal nursing home regulations mandate specific protocols for both medication administration and incident reporting to protect resident safety. The Centers for Medicare & Medicaid Services requires facilities to maintain detailed policies ensuring staff follow manufacturer guidelines for all medications, particularly high-risk drugs like insulin.
For incident reporting, facilities must investigate all allegations of abuse and report findings to appropriate authorities. This requirement exists because nursing home residents are considered a vulnerable population who may be unable to advocate for themselves or report incidents independently.
Professional nursing standards emphasize the "five rights" of medication administration: right patient, right drug, right dose, right route, and right time. The timing component is especially critical for medications like rapid-acting insulin, where even minor delays can have serious consequences.
Additional Issues Identified
The inspection also identified that the facility had previously addressed compliance issues related to behavioral incidents. Documentation showed the interdisciplinary team had met after incidents to implement changes, reviewed policies for proper implementation, notified providers and resident representatives, and completed both group and individual staff education on redirecting residents with behavioral issues.
An administrative nurse confirmed during the inspection that staff were expected to follow manufacturer guidelines for rapid-acting insulin administration, indicating awareness of proper protocols that weren't being consistently implemented.
The facility's own abuse prevention policy correctly outlined reporting requirements and timeframes, demonstrating that appropriate policies existed but weren't being followed in practice.
These violations highlight the importance of consistent staff training, policy implementation, and supervisory oversight in nursing home operations. While policies and corrective actions were in place, the inspection revealed gaps between written procedures and actual practice that placed residents at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benedictine Living Center of Garrison from 2024-07-24 including all violations, facility responses, and corrective action plans.
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