Resident 148 at Ridgeview Healthcare & Rehab Center had been receiving intravenous antibiotics through a subclavian catheter — a long tube placed under the skin into a vein near the heart — to treat a bone infection in his left ankle and foot. On July 20, 2024, staff attempted to change the dressing around the catheter site.
The resident later told emergency room personnel that "the staff used scissors to help remove the dressing and they nicked the catheter causing it to leak." The emergency room nurse confirmed finding "a small linear laceration to the catheter causing the catheter to leak at that site."
The incident began when a registered nurse tried to flush the catheter and noticed "fluid into dressing around site." The nurse immediately stopped the flush and reinforced the dressing, noting no bleeding or redness. The facility contacted interventional radiology at the hospital to request a catheter replacement.
But the hospital couldn't schedule the procedure until Monday, July 22. When staff suggested placing a temporary peripheral IV line, the resident refused and requested emergency room evaluation instead.
At the emergency room, doctors placed a new peripheral line and administered the resident's scheduled antibiotic dose. The resident returned to the facility later that day with the temporary line in place.
Federal inspectors found the facility failed to demonstrate that licensed practical nurses were properly trained to handle IV treatments, as required by Pennsylvania nursing regulations. The state nursing practice act requires facilities to provide "inservice instruction and supervised practice to insure competent performance" of IV procedures.
The facility's IV policies didn't comply with state requirements. While the policies addressed general IV administration, they failed to list specific IV fluids that LPNs could administer or provide required training protocols. Pennsylvania regulations mandate that LPN IV policies be updated annually and include detailed competency requirements.
During the inspection, the Director of Nursing confirmed that LPNs at the facility "should not be administering medications through intravenous lines, including PICC or CVC lines." Yet medication records showed an LPN had administered the resident's IV antibiotic on July 18.
The facility provided no documentation of staff education or competency evaluations for IV procedures. Inspectors found no evidence of the yearly training required by Pennsylvania's nursing practice act.
The administrator failed to provide evidence that the facility investigated the resident's allegation about the damaged catheter or verified whether staff were trained to perform the procedure.
This wasn't the only safety lapse inspectors documented. Three days before the IV incident, Resident 148 suffered a fall during transport to a medical appointment.
On July 22, the resident's wheelchair flipped backward while he was boarding the facility's transport van, causing him to fall and hit his head on the van floor. The resident complained of severe head, neck, and back pain rating 10 out of 10 and requested emergency room evaluation.
According to witness statements, the van driver had positioned the resident on the wheelchair lift platform and told him to wait while he walked around to enter the van. But the resident unlocked his wheelchair brakes and tried to back into the van himself.
Employee 5, a nurse aide escorting the resident, was standing on the ground next to the lift rather than inside the van. The van driver stated the resident "hit a lip where the lift attaches to the van and flipped backwards."
The resident returned from the emergency room that evening with no new injuries but remained "mad at what happened today," according to nursing notes. Staff added anti-tippers to his wheelchair following the incident.
During a re-enactment with inspectors, facility administrators concluded that escort staff should stand inside the van during future transports rather than on the pavement. But the administrator couldn't provide evidence that adequate supervision had been in place to prevent the original fall.
Inspectors also found failures in bowel care management. Resident 1, who had Parkinson's disease and multiple sclerosis, experienced a decline in bowel continence that staff failed to address with individualized interventions.
The resident had been continent of bowels according to assessments in December 2023 and March 2024. But by May 2024, assessments showed the resident was "frequently incontinent of bowels."
A continence screening in April indicated the resident's diet was contributing to fecal incontinence and that she needed occasional laxatives or enemas. Yet the facility's only intervention was a general "check and change every 2 hours" protocol originally written for bladder incontinence.
The Director of Nursing confirmed during the inspection that "no measures had been attempted to address Resident 1's decline in bowel function." The facility had no individualized bowel management plan despite the documented decline.
The resident's care plan addressed bladder incontinence but included no interventions for the bowel problems that developed months later.
These violations highlight systemic problems with staff training and individualized care at the 200-bed facility on Pennsylvania Avenue. Resident 148's damaged IV catheter required emergency intervention that could have been avoided with proper staff competency. His transport fall occurred despite multiple staff members present during the procedure.
The facility's failure to address Resident 1's bowel incontinence with appropriate interventions represents a missed opportunity to restore function and dignity for someone already managing multiple chronic conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Healthcare & Rehab Center from 2024-07-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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