The November incident at PruittHealth-Marietta happened when certified nursing assistant KK was assigned 11 residents, seven of whom required mechanical lift assistance. She got help with six transfers but found no one available for the seventh.
KK used the lift anyway to move the resident from chair to bed. The top of the lift swing bumped the resident in the head after it "swiveled out of control after the strap was released," according to her written statement eight days later.
The resident suffered from severe cognitive impairment and functional quadriplegia. Federal inspectors who reviewed the case in January found the facility failed to provide adequate staff to prevent injuries during mechanical lift transfers.
KK wrote that she didn't see any signs of injury immediately after the incident and proceeded to give the resident a bath. Later that morning, she transferred the resident from bed to chair again, still seeing no visible injury.
But the next day, a staff member noticed discoloration on the left side of the resident's forehead while the person sat in the dining hall. The facility's investigation two weeks later confirmed the resident was injured when struck by the mechanical lift.
The Administrator confirmed that facility policy requires two people when transferring a resident with a mechanical lift. All nursing staff receive education and competency checks on proper lift usage before working on the floor, she said.
But the policy wasn't followed.
The Assistant Director of Nursing conducted training after the incident on proper mechanical lift use, including how many people should be present, correct sling sizing, and ensuring resident behaviors are appropriate for safe transfers. Staff had to demonstrate competency through return demonstrations.
The Administrator said staff who don't properly use mechanical lifts on residents face suspension during investigation. She expected staff to follow the policies and training provided.
Medication Errors Put Residents at Risk
The same January inspection found nurses crushing medications that cannot be safely crushed and failing to measure topical medication doses correctly.
During a morning medication pass, inspectors watched Licensed Practical Nurse AA crush extended-release potassium chloride capsules and rivastigmine tartrate capsules for a resident who had difficulty swallowing. Both medications were clearly marked "Do Not Crush" on the packaging and physician orders.
The nurse mixed the crushed medications with water, telling inspectors the resident couldn't swallow them whole. When questioned, she agreed she should have contacted the pharmacist or doctor to explore alternative medication forms.
The resident's medical orders from 2021 specified that medications should be crushed and taken orally. But newer orders for the potassium chloride capsules, dated January 16, included special instructions: "Do Not Crush. Ok to open capsule and pour in apple sauce."
The rivastigmine order from November 2023 also carried special instructions: "Do not crush."
Facility policy requires nurses to contact the pharmacy first when residents can't swallow medications, then get physician approval for alternative forms. Extended-release and enteric-coated medications generally shouldn't be crushed without specific physician orders documenting that benefits outweigh risks.
The same nurse also failed to measure diclofenac gel correctly. She squeezed an unmeasured amount into a small medicine cup without using the measuring card that comes with the medication. The physician had ordered exactly 4 grams to be applied to the resident's left knee four times daily.
When asked how she ensured she was giving the correct dose, the nurse admitted she didn't know how to measure it correctly.
Two unit managers gave conflicting guidance about measuring the topical medication. One said the correct method was squeezing gel onto a measuring card. The other said she squeezed gel into a medication cup, using "somewhere around 5-15 ml" but was unclear on the precise amount. She didn't know measuring cards came with the medication.
The Director of Nursing said staff "do not measure and administer it liberally" when referring to the diclofenac ointment. She wasn't aware measuring cards came with the medication and wasn't sure if there was a policy about proper measurement.
The facility pharmacist confirmed that special instructions appear on medication records when drugs cannot be crushed or capsules cannot be opened. Alternative forms like liquid potassium chloride and transdermal rivastigmine patches are available when residents have swallowing difficulties.
Infection Control Failures
Inspectors also found infection control violations affecting two residents.
One resident's oxygen tubing was draped over the concentrator and touching the floor instead of being stored hygienically in the attached bag. The resident used oxygen as needed rather than continuously, but the nasal cannula remained connected and improperly stored when not in use.
The Assistant Director of Nursing confirmed the tubing should be bagged when not in use and never placed on the floor or concentrator. He provided new tubing after inspectors pointed out the problem.
Another resident on Enhanced Barrier Precautions wasn't receiving proper infection control protection. The resident had a stage II pressure ulcer and gastrostomy tube, requiring staff to wear gowns and gloves during high-contact care activities.
But inspectors observed a licensed practical nurse completing tube feeding without any personal protective equipment. The resident's room wasn't marked for Enhanced Barrier Precautions, despite orders placing the resident on these precautions due to wounds and medical devices.
The nurse left feeding supplies unlabeled on the bedside table after completing the procedure. Personal protective equipment was available on a cart in the hallway but wasn't used.
The Assistant Director of Health Services acknowledged the room wasn't properly marked and said it would be corrected. By the end of the shift, proper signage was in place.
Environmental Hazards Throughout Facility
Maintenance problems posed additional risks to all 106 residents. Inspectors found dust buildup on air conditioning filters, loose PTAC units, exposed insulation, peeling trim, and black substances on shower room tiles and kitchen ceilings.
In one resident room, a privacy curtain rail had a brown item wedged into the end and exposed insulating spray foam on the wall. Another room had a loose air conditioning unit.
The first-floor shower room had orange substances on the floor and clusters of black substances between tiles. Kitchen areas showed black substances on dish room ceilings and brown and black substances on storage room ceiling vents.
Residents complained about the shower room conditions during a council meeting. The Maintenance Director acknowledged being unaware of these problems and said staff should report concerns through the electronic building management system.
He works alone without assistants, making it challenging to address building concerns promptly. The Administrator said air conditioning units should be checked weekly and ceiling vents cleaned monthly, with concerns addressed immediately to prevent negative outcomes.
The January 16 inspection covered quality of care, accident prevention, infection control, and environmental safety standards. PruittHealth-Marietta serves residents with complex medical needs including cerebral conditions, pneumonia, pressure ulcers, and feeding tubes requiring specialized care protocols.
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.