The resident at Calvert County Nursing Center required a sit-to-stand transfer device according to their care plan. But when two nursing assistants entered the room to help with a transfer from bed to wheelchair, one assistant said they could lift the resident manually.
Both the resident and the third nursing assistant objected, insisting the sit-to-stand device should be used. The second assistant was "in a hurry" and proceeded with the manual lift anyway.
"I felt the pain in my arm and heard the snap when I lifted my arms around the GNA's neck," the resident told inspectors during a January interview.
The third nursing assistant confirmed hearing the fracture occur. "I immediately got the RN and then stayed with the resident to comfort them," they said.
The resident's care plan had required sit-to-stand transfers since February 4, 2022. Their assessment showed they depended on staff for all transfers and required support from two or more people to move between surfaces safely.
The facility's Director of Nursing acknowledged the assistant "did not follow the GNA transferring Kardex." The resident was sent to the emergency room for treatment of the fractured right arm.
Federal inspectors found the facility failed to provide a safe environment during transfers for the high-risk resident. The violation was classified as causing actual harm.
Staff received education on safe lifting protocols on September 27, 2024, more than a month after the incident. The nursing assistant who caused the injury was suspended and not allowed to return to the facility.
The Director of Nursing initially blamed the delay in staff education on the resident's failure to immediately report that the sit-to-stand device wasn't used. But the resident had reported the improper transfer to nursing leadership the same day it occurred.
Medication Shortages and Contamination
The same inspection revealed multiple medication safety failures affecting resident care.
Licensed Practical Nurse 12 documented that two prescribed medications were "on hold" for four consecutive days in late October and early November 2024. The medications included Pramipexole for restless leg syndrome and Carvedilol for high blood pressure.
When questioned, the nurse said: "I don't know why I have documented this except that the medication possibly wasn't here from the pharmacy yet." Progress notes indicated the facility was "awaiting from pharmacy" but the nurse admitted not checking available stock medications.
The Director of Nursing said nurses should contact the prescribing physician when medications aren't available from the pharmacy. "I can't confirm that he gave the medications," she said about the nurse's documentation.
During medication administration rounds, inspectors observed staff contaminating pills. A medication technician dropped blood pressure medication on top of the medication cart, picked it up with bare hands, and placed it back in the medication cup for administration.
"She should have disposed of the medication after dropping it and should not have touched the pill with her hands," the technician acknowledged.
A unit manager dropped a blood pressure pill on paper atop the medication cart and scooped it into a medication cup for administration. "At least I didn't touch it with my hands," the manager said, admitting uncertainty about whether the paper was clean.
Infection Control Violations
A registered nurse entered the room of a resident with MSSA blood infection without wearing required protective equipment. The resident was on contact precautions with clear signage instructing staff to wear gowns and gloves before room entry.
The nurse connected intravenous antibiotics to the resident's central line catheter while wearing no protective equipment. When questioned, the nurse said he "doesn't believe he needed to wear PPE, because the resident only has pneumonia in his lungs."
The facility's infection control specialist confirmed the resident was on contact isolation due to MSSA bacteremia in the blood. "The contact isolation sign is on the door, it instructs the staff of what is expected to do, and there is no exception," she said.
Staff also left medication carts unlocked and unattended during patient care. A registered nurse left her cart unlocked with an insulin pen on top while washing hands in a resident's bathroom, putting medications out of her sight and accessible to others.
Dirty Ice Machines and Missing Documentation
Kitchen and unit ice machines showed clear and brownish colored smears with debris. The kitchen ice machine had an orangish film on interior surfaces.
The Assistant Dietary Manager confirmed both machines had contamination. Maintenance staff cleaned the interiors while kitchen staff handled external surfaces, but no clear policy existed for comprehensive ice machine cleaning.
The Director of Nursing said she was "unsure who the responsibility for keeping the ice machines in the facility clean fell upon." The facility failed to provide cleaning policies before the inspection concluded.
Staff routinely left computers unlocked with resident medical information exposed during patient care activities. Nurses and unit managers confirmed they improperly left protected health information accessible while away from workstations.
Antibiotic and Vaccination Failures
The facility prescribed antibiotics without documenting symptoms that would justify treatment. One resident received Ciprofloxacin for urinary tract infection, but nursing notes only showed "urine specimen collected" with no documentation of infection symptoms.
The infection preventionist couldn't determine if the antibiotic met clinical criteria because "the nurse did not document" the resident's signs and symptoms.
Four residents received flu vaccines without documented education about the immunizations. The same residents lacked documentation showing they were offered or educated about pneumococcal vaccines, despite CDC recommendations for their age group.
The infection preventionist said she "erroneously marked No" on forms indicating education wasn't provided, though she claimed to have given vaccine information to residents.
The facility operates 98 beds and serves residents requiring skilled nursing care and rehabilitation services in southern Maryland.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Calvert County Nursing Ctr. from 2025-01-17 including all violations, facility responses, and corrective action plans.
