CYNTHIANA, KY - A January 2025 inspection at Harrison Nursing and Rehabilitation Center revealed serious deficiencies in medication management and care planning that potentially compromised resident safety and quality of care.
Dangerous Medication Management Practices Exposed
Federal inspectors documented widespread problems with medication storage and labeling that violated professional standards. The violations centered on expired medications remaining in active use and improperly labeled drugs throughout the facility's medication distribution system.
On multiple medication carts and treatment carts, inspectors found expired insulin, inhalers, and other critical medications that should have been removed from service. One particularly concerning discovery involved insulin lispro with an expiration date of January 16, 2025 that was still being used by nursing staff. When questioned, Licensed Practical Nurse 3 admitted she "was unaware the insulin was expired, and it should have been discarded by the expiration date."
The medication safety violations extended beyond expired drugs to include widespread labeling failures. Inspectors documented insulin vials and pens without opening dates, antifungal creams removed from their original packaging without proper labels, and medications stored without identification. On the treatment cart, inspectors found nystatin powder with no label and multiple antifungal medications that were unbagged and improperly stored.
These medication management failures represent significant safety risks for residents with diabetes, respiratory conditions, and other chronic illnesses who depend on accurate medication administration. When insulin expires, its effectiveness diminishes, potentially leading to dangerous blood sugar fluctuations. Unlabeled medications create opportunities for dangerous mix-ups that could result in residents receiving wrong medications or incorrect dosages.
Critical Oxygen Therapy Violations Threaten Respiratory Health
The inspection revealed serious failures in respiratory care for a resident with chronic respiratory failure requiring continuous oxygen therapy. Despite physician orders for oxygen at 3 liters per minute (LPM) continuous by nasal cannula, inspectors found the oxygen concentrator set at incorrect levels on multiple occasions.
Over four consecutive days of observation, the oxygen flow rate varied dramatically from the prescribed 3 LPM. Inspectors documented settings of 4.5 LPM on January 21, 5 LPM on January 22, and 4 LPM on both January 23 and 24. When interviewed, the resident stated her oxygen flow rate should be set at 3 LPM and claimed she did not change the settings, explaining "It's [oxygen concentrator] old and won't hold the setting." When asked if anyone had checked the concentrator, she responded "No."
This oxygen therapy failure is particularly concerning given the resident's medical history of acute on chronic respiratory failure with both hypercapnia (excess carbon dioxide) and hypoxia (insufficient oxygen). For patients with these conditions, precise oxygen delivery is critical. Too little oxygen can worsen hypoxia and lead to organ damage, while excessive oxygen can suppress the respiratory drive in patients with chronic CO2 retention, potentially causing respiratory failure.
The facility's own Oxygen Usage Policy required regular assessments to monitor oxygen needs and proper documentation of flow rates. However, nursing staff failed to implement these basic safety protocols, and the resident's oxygen orders were not even included on the Medication Administration Record or Treatment Administration Record, making it impossible to track compliance.
Inadequate Care Planning Compromises Individualized Care
Inspectors identified significant deficiencies in comprehensive care planning that left vulnerable residents without proper individualized care protocols. The most striking example involved a hospice patient whose care plan was not updated for four days after hospice admission, despite the immediate need for specialized end-of-life care interventions.
Another resident with chronic respiratory failure and documented non-compliance with treatments lacked a care plan addressing her oxygen therapy needs and behavioral challenges. Despite staff acknowledging the resident's tendency to adjust her oxygen concentrator settings, no interventions were developed to address this safety concern.
Care plans serve as the roadmap for individualized resident care, providing nursing staff with specific interventions tailored to each resident's unique needs, conditions, and challenges. When care plans are incomplete or delayed, residents may not receive appropriate care, potentially leading to deterioration of their condition or safety incidents.
Systemic Quality Assurance Failures
The inspection revealed that these violations were not isolated incidents but represented systemic failures in the facility's Quality Assurance Performance Improvement (QAPI) program. Notably, the expired insulin violation was a repeat finding from a previous 2024 inspection, indicating the facility's quality improvement processes had failed to prevent recurring medication safety problems.
Federal regulations require nursing homes to maintain comprehensive, data-driven QAPI programs that identify potential problems and implement lasting solutions. The recurrence of medication safety violations suggests fundamental weaknesses in the facility's ability to monitor, analyze, and correct deficient practices.
Medical Context and Industry Standards
These violations represent departures from established healthcare standards that exist to protect vulnerable nursing home residents. Proper medication management requires strict adherence to the "five rights" of medication administration: right patient, right drug, right dose, right route, and right time. Expired or unlabeled medications compromise multiple aspects of this safety framework.
Oxygen therapy requires continuous monitoring because respiratory conditions can change rapidly, and incorrect oxygen levels can have immediate life-threatening consequences. Industry standards require regular equipment checks, accurate documentation, and staff training on respiratory care protocols.
Care planning standards emphasize the importance of individualized, person-centered approaches that address each resident's specific needs and challenges. When residents enter hospice care or demonstrate non-compliance with critical treatments, care plans must be immediately updated to ensure appropriate interventions are in place.
Additional Issues Identified
The inspection also documented problems with narcotic disposal procedures, including controlled substances that remained in medication carts days after a resident's death. Staff acknowledged weekly medication cart audits were supposed to occur but clearly failed to identify and address the widespread problems documented by inspectors.
Treatment cart organization was also deficient, with a pharmacy technician explaining that medications were routinely removed from protective bags and required monthly reorganization efforts to match medications with proper packaging.
The facility's Administrator acknowledged that "it was important so residents did not receive wrong or expired medications" and that care plans should ensure "care was delivered as prescribed." However, the widespread nature of the violations suggests significant gaps between stated expectations and actual implementation of safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grand Haven Nursing Home from 2025-01-24 including all violations, facility responses, and corrective action plans.
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