MARIETTA, GA - Federal inspectors documented multiple safety violations at PruittHealth - Marietta during a January 16, 2025 inspection, including dangerous medication administration practices and an incident where a resident was injured during an improperly supervised mechanical lift transfer.
Dangerous Medication Administration Practices Identified
Inspectors observed a Licensed Practical Nurse (LPN) crushing extended-release medications that should never be altered, potentially causing serious adverse effects for residents. During the medication pass observation, the nurse crushed extended-release potassium chloride capsules and rivastigmine tartrate capsules, both of which had clear "Do Not Crush" instructions on their packaging and physician orders.
The medications involved included potassium chloride, an essential electrolyte supplement used to treat low potassium levels, and rivastigmine tartrate, a medication used to treat dementia symptoms. Both medications are formulated as extended-release to provide steady therapeutic levels throughout the day. When crushed, these medications can deliver their entire dose immediately, potentially causing dangerous side effects.
According to the inspection report, when questioned about the practice, "LPN AA agreed that she should have contacted the pharmacist or the doctor to explore alternative forms of the medications." The nurse stated she crushed the medications because the resident could not swallow them, but failed to follow proper protocols for medication modification.
The facility's own policy clearly states that extended-release or enteric-coated medications "should generally not be crushed and require a physician-specific order to do so." The policy also requires that any need for crushing medications be indicated on the medication administration record so all nursing staff are aware and the consultant pharmacist can advise on safety and alternatives.
Improper Dosing of Topical Medications
Inspectors also documented improper administration of diclofenac gel, an anti-inflammatory medication used to treat pain. The physician had ordered a specific 4-gram dose to be applied to the resident's left knee four times daily. However, the nurse was observed squeezing an unmeasured amount into a medicine cup without using the measuring card that comes with the medication.
When questioned about dosage accuracy, "the LPN AA admitted she did not know how to measure it correctly." This practice could result in either underdosing, which would provide inadequate pain relief, or overdosing, which could increase the risk of side effects.
The medication comes with a measuring card specifically designed to ensure accurate dosing, but multiple nursing staff interviewed were unaware of this tool. Even the Director of Nursing acknowledged not knowing about the measuring card and stated they "do not measure and administer it liberally."
Medical Significance of Proper Medication Administration
Extended-release medications are specifically formulated to provide controlled drug release over extended periods. When these medications are crushed, the controlled-release mechanism is destroyed, causing the entire dose to be released immediately. This can lead to:
- Toxic peak concentrations that exceed safe therapeutic levels - Shortened duration of action requiring more frequent dosing - Increased risk of side effects from rapid drug absorption - Reduced therapeutic effectiveness due to improper dosing intervals
For potassium chloride specifically, crushing extended-release formulations can cause severe gastrointestinal irritation, ulceration, and potentially dangerous fluctuations in blood potassium levels. Rivastigmine, when not properly dosed, can cause increased side effects including nausea, vomiting, and diarrhea, while potentially reducing its effectiveness in managing dementia symptoms.
Topical medications like diclofenac gel require precise dosing to achieve therapeutic benefits while minimizing systemic absorption and potential side effects. Overdosing topical anti-inflammatory medications can increase the risk of skin irritation and systemic effects.
Resident Injured During Improper Lift Transfer
In a separate incident that resulted in actual harm, a resident with severe cognitive impairment and functional quadriplegia was injured when a Certified Nursing Assistant (CNA) attempted to transfer them using a mechanical lift without the required second person present.
The incident occurred on November 5, 2024, when CNA KK was assigned 11 residents, seven of whom required mechanical lift assistance. According to the CNA's written statement, she was able to get help with six residents but "there was no one available to assist her with the seventh resident." She proceeded to use the mechanical lift alone, which resulted in the lift's swing arm hitting the resident in the head, causing bruising to the left eye.
The facility's investigation confirmed that "the resident was injured after R715 head was bumped by the Hoyer lift." The facility's own policy requires two people to be present when transferring residents with mechanical lifts, a standard safety protocol designed to prevent exactly this type of injury.
Industry Standards for Safe Transfers
Mechanical lifts are essential equipment in nursing homes for safely transferring residents who cannot support their own weight. However, these devices require proper training and adequate staffing to operate safely. Industry standards universally require:
- Two-person operation for all mechanical lift transfers - Proper sling sizing and positioning to ensure resident security - Assessment of resident behavior and cooperation before beginning transfer - Regular equipment maintenance and safety checks
The resident involved in this incident had multiple conditions that made them particularly vulnerable to injury, including functional quadriplegia, spinal stenosis, and severe cognitive impairment. These conditions require extra caution during transfers and make the presence of adequate staff even more critical.
Infection Control Lapses Documented
Inspectors identified several infection control violations that could increase residents' risk of developing healthcare-associated infections. These included improper storage of oxygen equipment and failure to use required personal protective equipment (PPE).
In one case, oxygen tubing for a resident recovering from pneumonia and COVID-19 was observed "draped over" the concentrator with "portions touching the floor" rather than being stored hygienically in the designated bag. Contaminated oxygen equipment can introduce bacteria directly into a resident's respiratory system, particularly dangerous for those with compromised lung function.
In another case, nursing staff failed to use required gowns and gloves when providing care to a resident on Enhanced Barrier Precautions due to wounds and medical devices. The resident's room was not properly marked for the special precautions, and staff were observed providing direct care without appropriate PPE.
Facility Maintenance and Environmental Concerns
The inspection also revealed multiple environmental hazards throughout the facility, including black substances in shower areas and kitchen ceilings, damaged PTAC units, and exposed insulation. These conditions affect all 106 residents and could contribute to respiratory problems and other health issues.
The maintenance director acknowledged being unaware of many of these issues and stated he is the only maintenance employee, making it "challenging to address all the concerns in the building right away."
Additional Issues Identified
The inspection documented several other areas of concern, including inadequate marking of rooms requiring special infection control precautions and general maintenance issues affecting resident comfort and safety. Residents themselves raised concerns about conditions in common areas during interviews with inspectors.
These violations at PruittHealth - Marietta highlight critical gaps in medication safety, staffing adequacy, and infection control that directly impact resident safety and well-being. The facility must address these issues to ensure proper care and prevent future incidents that could harm vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pruitthealth - Marietta from 2025-01-16 including all violations, facility responses, and corrective action plans.
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