PruittHealth Marietta: Medication Safety Violation - GA
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.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PRUITTHEALTH - MARIETTA in MARIETTA, GA was cited for violations during a health inspection on January 16, 2025.
Both medications are formulated as extended-release to provide steady therapeutic levels throughout the day.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.