ALTAMONT, NY - A state health inspection at The Grand Rehabilitation and Nursing at Guilderland revealed systemic failures in medication administration and medical record keeping, with multiple residents missing critical doses of psychiatric medications, antibiotics, and other essential treatments over extended periods.
Critical Medication Failures Documented Across Multiple Units
The inspection, completed March 7, 2025, documented that Resident #47 did not receive prescribed psychiatric medication at bedtime for 12 consecutive days from November 25 to December 6, 2024. The resident's psychiatric medication was ordered to be administered at 9:00 PM daily, but staff failed to provide these doses. On November 29, 2024, at 9:00 AM, the resident experienced decompensation and was hospitalized at their request.
Psychiatric medications require consistent administration to maintain therapeutic blood levels. When these medications are abruptly discontinued or doses are missed, patients can experience withdrawal symptoms, return of psychiatric symptoms, and potentially dangerous decompensation. The 12-day gap in this resident's medication regimen represents a serious breach in psychiatric care standards.
Two other residents failed to receive complete courses of prescribed antibiotics. Resident #12 received only 10 of 20 prescribed antibiotic doses, while Resident #23 received only 4 of 8 prescribed doses. Incomplete antibiotic courses can lead to treatment failure, prolonged infections, and development of antibiotic-resistant bacteria. When antibiotics are prescribed, completing the full course is essential to eliminate the infection and prevent complications.
Dangerous Delays in Time-Sensitive Treatments
The facility also failed to provide timely administration of critical medications for several residents. Resident #77 was prescribed medication to lower their potassium level on December 21, 2024, but did not receive it until December 25, 2024 - a four-day delay. Elevated potassium levels (hyperkalemia) can cause irregular heart rhythms, muscle weakness, and in severe cases, cardiac arrest. Medications prescribed to lower potassium are typically ordered urgently because hyperkalemia can become life-threatening within hours to days.
Resident #327 did not receive prescribed antibiotics for two days after they were ordered. This delay in initiating antibiotic therapy can allow infections to progress, potentially leading to sepsis or other serious complications. Standard medical practice requires antibiotics to be started as soon as possible after diagnosis of a bacterial infection, particularly in elderly nursing home residents who are at higher risk for rapid deterioration.
For diabetic care, Resident #6 did not receive finger stick blood sugar checks for over 12 hours after admission. Blood glucose monitoring is essential for diabetic patients, especially during the admission process when medication regimens are being established. Unmonitored blood sugar levels can result in hypoglycemia (dangerously low blood sugar) or hyperglycemia (dangerously high blood sugar), both of which can cause serious complications including confusion, seizures, or diabetic coma.
Widespread Documentation Failures and Potential Falsification
The inspection revealed extensive problems with medical record accuracy and completion. Narcotic count record books for all three units showed numerous missing signatures from nurses who were supposed to verify controlled substance counts during shift changes. Unit A's narcotic book had missing signatures on at least 20 occasions between February 4 and February 27, 2025. Unit B showed similar gaps, with some dates that were blank on February 28 later appearing signed when copies were provided on March 2, raising concerns about backdating of records.
During interviews, Licensed Practical Nurse #2 admitted that "if they saw a blank signature space in the book and knew they worked that shift, they would sign it, even if it were days later." This practice violates fundamental documentation standards, as narcotic counts must be signed at the time they are performed, not retrospectively.
The inspection also uncovered apparent falsification of vital signs documentation. Resident #23's vital signs showed identical readings repeated across multiple consecutive days - a medical impossibility. For example, the exact same blood pressure (132/68), temperature (97.4), pulse (68), respirations (17), and oxygen saturation (96%) were documented on eight different dates in January 2025. When confronted with this evidence, Licensed Practical Nurse #5 stated they "would not expect a resident to have the same vital signs multiple days in a row" and could not explain the duplicate entries. Nurse Practitioner #1 confirmed that "duplicate vital signs over several days would be highly unusual."
Additionally, Resident #53's treatment record showed wound dressing changes being documented even after the wound had healed. A wound assessment on January 14, 2025, documented the wound was healed, yet dressing changes continued to be documented through March 5, 2025. When interviewed, the resident denied having any open areas requiring dressing, and the nurse who documented the treatment could not explain why they recorded providing care that was not needed.
Infection Control Violations Put Vulnerable Residents at Risk
The facility failed to implement enhanced barrier precautions for residents with indwelling medical devices, despite having a policy requiring such measures. Three residents with high-risk devices - including hemodialysis catheters, urinary catheters, and gastrostomy tubes - were not placed on enhanced barrier precautions as required by facility policy and infection control standards.
Indwelling medical devices significantly increase the risk of healthcare-associated infections, particularly with multi-drug resistant organisms. Enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities, are essential to prevent the spread of infections in nursing home settings. The failure to implement these precautions puts not only the affected residents at risk but also threatens the health of other vulnerable residents in the facility.
Administrative Response and Systemic Issues
When interviewed, the facility's Director of Nursing #1 stated they were aware of missing medications from the pharmacy but claimed the medication issues "just came to light over the last week during survey." The Administrator similarly stated they had not received any medication error reports in January or February 2025, despite the documented failures occurring during this period.
The Medical Director #1, when asked about increasing oversight to ensure compliance, stated they "believed that because they had talked to the girls they would be compliant, and did not intend to increase visits unless it was needed." This response suggests a lack of understanding of the severity and systemic nature of the problems identified.
Additional Issues Identified
Beyond the major violations detailed above, the inspection documented additional care failures including Resident #14 not being offered personal care assistance, Resident #20's feet not being assessed regularly despite orders, and both Resident #23 and Resident #77 not having vital signs monitored as ordered during changes in their conditions. The facility's Quality Assurance Performance Improvement committee, which is supposed to identify and address systemic problems, had only met once since the current Director of Nursing's promotion, indicating a breakdown in the facility's quality oversight mechanisms.
The inspection also revealed that the facility lacked a functional system for tracking and reporting medication errors, with no missed medication forms being submitted to administration despite the numerous documented failures. Staff reported they were never told there were insufficient personnel to complete medication administration or resident care, yet the pattern of missed medications and incomplete documentation suggests significant operational challenges that went unreported through proper channels.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Grand Rehabilitation and Nrsg At Guilderland from 2025-03-07 including all violations, facility responses, and corrective action plans.
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