ORANGE, NJ - Federal inspectors cited Alaris Health at St Mary's for immediate jeopardy violations after a ventilator-dependent resident suffered a traumatic hematoma to the right eye during an improperly supervised mechanical lift transfer.
The January 2025 inspection revealed serious safety protocol failures affecting the facility's most vulnerable residents, including those dependent on life-support equipment.
Traumatic Eye Injury During Transfer
The incident occurred on November 6, 2024, when Resident #264, a patient in a persistent vegetative state who required mechanical ventilation, sustained significant facial trauma during what should have been a routine transfer from a recliner chair to bed.
The resident, who was completely dependent on staff for all care due to acute and chronic respiratory failure, hypoxia, epilepsy, and tracheostomy status, was being moved using a mechanical lift device when the injury occurred.
According to facility staff statements, CNA #1 initially reported discovering the resident with facial discoloration and swelling around the right eye after an afternoon positioning. However, conflicting accounts emerged during the investigation that raised serious concerns about the circumstances of the injury.
"On 11/06/24, in the evening I put resident back in bed with a mechanical lift. Once back in bed, I noticed resident had redness to face by eye," CNA #1 documented in one statement, though this contradicted her earlier report of finding the injury before the transfer.
Protocol Violations and Safety Failures
Federal regulations require that ventilator-dependent residents receive specialized supervision during transfers due to the complexity of their medical equipment and high risk of injury. The investigation revealed multiple protocol violations:
The facility's own respiratory therapist confirmed that transfers of ventilator-dependent residents require two qualified staff members - typically a nurse and a CNA, or a respiratory therapist supervising the procedure. This protocol exists because ventilator patients cannot be safely moved without ensuring their life-support equipment remains properly positioned and functional.
However, evidence showed that CNA #1 performed the transfer alone, without the required nursing supervision. When CNA #2 eventually entered the room, she found the resident already positioned on the mechanical lift with the visible facial injury.
"CNA #1 had Resident #264 on the mechanical lift alone in the room. CNA #2 was not in the room when CNA #1 initiated the transfer," according to the facility's own investigation summary.
Investigation Inconsistencies
The facility's investigation revealed troubling inconsistencies in staff accounts of the incident. CNA #1 provided conflicting statements about when she first noticed the injury, initially claiming she discovered it before the transfer, then later stating she observed it afterward.
During surveyor interviews, CNA #1 admitted that "another co-worker coached her to write the second statement" and that she had not actually observed any injury while the resident was sitting in the chair. She also acknowledged that the evening shift was "very chaotic" and that she moved on to attend other residents rather than remaining with the injured patient until medical assessment could be completed.
The facility's Director of Nursing acknowledged the discrepancies but could not provide rationale for failing to clarify these contradictions before submitting the investigation to state health officials.
Medical Consequences and Emergency Response
The severity of the facial trauma required immediate medical intervention. The facility's Nurse Practitioner ordered an emergency hospital transfer for CT scanning to rule out orbital fractures after observing the significant bruising and swelling.
Hospital evaluation confirmed a traumatic hematoma to the right orbit (eye socket), indicating substantial force was applied to this vulnerable patient's face during the transfer incident. For a resident in a persistent vegetative state who cannot protect themselves or communicate pain, such injuries represent a serious breach of the duty of care.
The medical implications of orbital trauma in ventilator-dependent patients are particularly concerning. These residents often have compromised circulation and healing capacity, making them more susceptible to complications from injuries. Additionally, facial trauma near the eyes can potentially interfere with ventilator mask positioning or other respiratory equipment.
Systemic Safety Concerns
The investigation uncovered broader systemic issues beyond the single incident. Staff interviews revealed that some CNAs working as "floaters" to the ventilator unit were not properly trained to transfer residents with ventilator equipment attached.
The respiratory therapist noted that "some CNAs worked as floaters to the unit and they were not trained to transfer residents with the ventilator attached" and confirmed that safety protocols required either nursing supervision or respiratory therapist oversight for such transfers.
Notably, the facility could not produce a written policy specifically governing the transfer of ventilator-dependent residents, despite the specialized nature of this care and the associated safety risks.
Additional Substance Abuse Violations
The inspection also uncovered serious failures in preventing illicit drug access for another resident. Resident #34, a patient receiving methadone treatment for opioid dependence, repeatedly tested positive for cocaine, opiates, and morphine despite being under facility care.
Staff documented finding drug paraphernalia in the resident's room on multiple occasions, including glass pipes, vape pens, and improvised drug-use devices. The resident was observed receiving substances from individuals outside the facility's perimeter fence during supervised smoking breaks.
Despite implementing 1:1 monitoring temporarily, the facility's interventions proved inadequate. The resident continued accessing illicit substances through December 2024, demonstrating ongoing security and supervision failures.
Regulatory Response and Standards
Federal inspectors classified these violations as "immediate jeopardy" - the most serious citation level - indicating that the facility's failures posed immediate risk to resident health and safety.
The citation under F689 addresses the fundamental requirement that nursing homes protect residents from accidents and provide adequate supervision. For ventilator-dependent residents, this obligation includes ensuring that highly trained staff properly manage complex medical equipment during routine care activities.
Current federal standards require that nursing facilities maintain sufficient staffing levels and ensure that all staff receive appropriate training for the specific types of residents they serve. Facilities caring for ventilator-dependent residents must demonstrate competency in managing life-support equipment and understanding the elevated injury risks these vulnerable patients face.
Implications for Vulnerable Populations
These violations highlight particular risks facing nursing home residents who cannot advocate for themselves or report unsafe conditions. Residents in persistent vegetative states, those requiring mechanical ventilation, and patients with substance use disorders represent some of the most vulnerable populations in long-term care settings.
The facility's failure to maintain proper transfer protocols and its inability to prevent drug access demonstrates gaps in basic safety measures that all residents deserve. When facilities cannot adequately protect these high-risk residents, it raises questions about the safety of their entire resident population.
The conflicting staff statements and coaching of incident reports also suggest potential issues with transparency and accountability in the facility's safety culture, concerns that extend beyond any single incident.
These violations serve as a reminder of the specialized expertise required to safely care for medically complex nursing home residents and the critical importance of maintaining rigorous safety protocols in institutional care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alaris Health At St Mary's from 2025-01-23 including all violations, facility responses, and corrective action plans.
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