SCOTTSBLUFF, NE - Monument Rehabilitation and Care Center received multiple citations during a federal inspection in August 2024, with violations ranging from improper medication administration to infection control failures affecting the facility's 75 residents.
Critical Medication Safety Failures
Federal inspectors documented widespread problems with medication administration that posed significant risks to residents requiring diabetes care. The facility's medication error rate reached 16 percent - more than three times the maximum allowable rate of 5 percent established by federal regulations.
The most serious concerns involved improper insulin administration techniques. Inspectors observed medication aides failing to follow established protocols when preparing insulin injections for diabetic residents. According to the facility's own procedures, staff must prime insulin pens by holding them upright and allowing a test dose to emerge from the needle tip to ensure proper function and accurate dosing.
However, during multiple observations, inspectors documented medication aides consistently holding insulin pens downward during the priming process, which can trap air bubbles and result in inaccurate insulin doses. This occurred with three separate residents receiving insulin injections on different occasions.
When staff fail to properly prime insulin pens, air bubbles can remain in the medication delivery system, potentially causing residents to receive less insulin than prescribed. For diabetic residents, receiving inadequate insulin doses can lead to dangerous blood sugar spikes, increasing risks of diabetic complications, dehydration, and in severe cases, diabetic coma.
Additionally, inspectors found problems with blood glucose testing procedures. Staff were observed using the first drop of blood from finger pricks rather than wiping it away and testing the second drop, as required by medical standards. The first drop of blood can contain tissue fluid and contaminants that may produce inaccurate readings, potentially leading to inappropriate insulin dosing decisions.
Falls Prevention System Breakdown
The inspection revealed significant failures in fall prevention protocols for a high-risk resident with multiple sclerosis, seizure disorder, and dementia. Despite experiencing six documented falls between June and July 2024, including one resulting in a head injury requiring emergency room treatment, the facility failed to properly implement ordered safety interventions.
The resident's care plan specified placement of a specialized scoop mattress designed to alert the resident to bed edges and prevent falls. However, inspectors found the resident was sleeping on a regular flat mattress instead of the prescribed safety equipment. Staff interviewed during the inspection were unaware that the special mattress had been ordered as a fall prevention measure.
Effective fall prevention in nursing homes requires a multi-layered approach including environmental modifications, appropriate assistive equipment, staff training, and continuous monitoring. When facilities fail to implement ordered interventions, residents face increased risks of serious injuries including fractures, head trauma, and other complications that can significantly impact quality of life and health outcomes.
Medication Oversight Gaps
The facility failed to ensure proper pharmacist oversight of resident medications, with one resident going six months without required monthly medication reviews. Federal regulations mandate that licensed pharmacists review each resident's complete medication regimen monthly to identify potential drug interactions, unnecessary medications, and dosing concerns.
The affected resident was receiving multiple high-risk medications including insulin, antipsychotic medications, antidepressants, and blood pressure medications. Without regular pharmacist review, dangerous drug interactions or inappropriate medication combinations can go undetected, potentially causing adverse reactions, increased fall risk, or other serious health complications.
Monthly medication reviews serve as a critical safety net in nursing home care, where residents often take multiple medications and may have changing health conditions. These reviews help ensure medications remain appropriate, effective, and safe as residents' conditions evolve.
Antipsychotic Medication Violations
Inspectors identified improper management of antipsychotic medications, including failure to limit as-needed orders to the federally mandated 14-day maximum. One resident had an indefinite order for Haloperidol, an antipsychotic medication, without proper time limits or family notification requirements.
Federal regulations require facilities to inform residents and families about the risks, benefits, and potential adverse effects of antipsychotic medications. These powerful medications can cause serious side effects including increased fall risk, sedation, movement disorders, and in some cases, increased mortality risk in elderly patients with dementia.
The facility also failed to document attempts at gradual dose reduction, which is required to minimize unnecessary antipsychotic use and reduce potential harm to residents.
Food Safety and Infection Control Concerns
The inspection documented multiple infection control failures that could affect all residents. Kitchen dishwashing equipment was operating at temperatures below manufacturer specifications, with wash cycles reaching only 145°F instead of the required 160°F, and rinse cycles at 163°F rather than the mandated 180°F.
Proper dishwashing temperatures are essential for eliminating harmful bacteria and preventing foodborne illnesses, which can be particularly dangerous for elderly nursing home residents with compromised immune systems.
Additional infection control problems included failure to sanitize shared medical equipment between uses and inadequate review of employee health screenings. Staff were observed moving patient lift equipment between resident rooms without proper disinfection, creating potential pathways for infection transmission.
Additional Issues Identified
The facility also faced citations for inadequate pest control after inspectors discovered an active wasp nest in a courtyard area where residents spend time outdoors. The maintenance director acknowledged the nest had been present for approximately one week without remediation.
Staff training deficiencies were evident across multiple areas, with medication aides demonstrating incomplete knowledge of proper procedures for blood glucose testing, insulin administration, and eye drop application during observed interactions with residents.
The facility's lack of a comprehensive water management plan to prevent Legionella and other waterborne pathogens represented another significant gap in infection prevention protocols.
These violations highlight the importance of comprehensive staff training, consistent protocol implementation, and effective oversight systems in maintaining resident safety and quality care in nursing home settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monument Rehabilitation and Care Center from 2024-08-01 including all violations, facility responses, and corrective action plans.
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