AUBURN, WA - Federal inspectors documented a dangerous 20% medication error rate at North Auburn Rehab & Health Center during an April 2025 inspection, four times higher than the federal maximum of 5%.
Critical Medication Administration Failures
The facility failed to properly administer 5 of 25 medications observed during the inspection, creating significant safety risks for residents. Staff administered medications without following proper timing protocols, gave wrong medications, and ignored safety procedures designed to maximize therapeutic effectiveness.
During one observation, a Licensed Practical Nurse administered multiple eye drops to a resident within seconds of each other, despite facility policy requiring 3-5 minute intervals between different eye medications. The nurse administered two different eye drops at 8:26 AM and 8:27 AM without the required waiting period.
"I know I gotta wait like 5 minutes between eye drops," the nurse acknowledged during the inspection, yet continued administering medications incorrectly.
Medical Significance of Proper Medication Timing
Proper spacing between eye drop administrations is medically critical. When eye drops are given too quickly, the first medication gets washed out by the second, preventing adequate absorption. This reduces therapeutic effectiveness and can lead to treatment failure.
For diabetic residents requiring blood sugar management, timing is equally crucial. Inspectors observed staff checking blood sugar levels and administering insulin 82 minutes after the scheduled time - well beyond the acceptable 30-minute window. Late insulin administration can result in dangerous blood sugar spikes and complications.
Wrong Medication Administration
In another serious error, staff gave a resident the wrong stool softener medication. Instead of administering the single-ingredient medication ordered by the physician, the nurse gave a combination medication containing two different stool softeners.
"I administered the wrong stool softener," the nurse admitted during questioning. This type of error can cause unexpected side effects or drug interactions, particularly concerning for residents taking multiple medications.
Broader Safety Violations Found
Beyond medication errors, inspectors documented multiple safety failures affecting resident care:
Bed Rail Safety Compromises: Seven residents had improperly installed or broken bed rails. One resident's bed rail was completely non-functional for several days, preventing them from repositioning themselves in bed as prescribed for pain management. "The left side of the bed rail was broken for a few days, and I could not reposition myself in bed," the resident reported.
Catheter Management Failures: Staff failed to follow proper protocols for urinary catheter use, including inadequate assessment for medical necessity and lack of discontinuation planning. One resident had a catheter placed after voiding trial failure, but staff never obtained proper post-void residual measurements or considered specialist consultation.
Nutrition and Hydration Lapses: The facility failed to ensure consistent weight monitoring for residents on prescribed weight loss programs, with gaps of over six weeks between weighings. Two residents lacked adequate hydration services, with "staff do not bring them water" according to resident reports.
Food Safety Concerns
Kitchen operations revealed serious sanitation failures. The dishwasher operated without proper sanitizing chemicals for an entire day, potentially exposing residents to foodborne illness. Staff discovered the sanitizer was completely absent during morning testing but failed to report the problem or take corrective action.
"There was no chemical," the dishwasher acknowledged, but admitted to not reporting the safety issue to supervisors.
Smoking Policy Enforcement
Despite being a non-smoking facility, staff failed to complete required smoking assessments for residents who smoke. One resident kept cigarettes and a lighter in their room without proper safety evaluation, creating potential fire hazards.
Medication Storage Violations
Both medication carts contained expired and discontinued medications, including drugs for residents who had been discharged months earlier. The medication room refrigerator held expired medications and improperly stored supplies that should have been disposed of promptly.
Record Keeping Deficiencies
The facility failed to maintain complete medical records for 25 of the residents reviewed. Critical documentation including podiatry consultations and safety device assessments were missing from resident files, potentially compromising continuity of care.
Regulatory Standards and Expectations
Federal regulations require nursing homes to maintain medication error rates below 5% to ensure resident safety. The 20% rate documented at North Auburn Rehab represents a serious departure from acceptable standards.
Proper medication administration protocols exist to prevent therapeutic failures and adverse reactions. When medications are given at wrong times, in wrong doses, or are entirely incorrect medications, residents face increased risks of complications and treatment failures.
Industry Context
Medication errors remain one of the most serious safety concerns in long-term care facilities. Proper timing, dosing, and administration techniques directly impact treatment outcomes for residents with complex medical conditions.
The violations at North Auburn Rehab highlight systemic issues in staff training, supervision, and quality assurance processes. Effective medication management requires consistent adherence to established protocols and regular monitoring of error rates.
Facility Response Required
The inspection findings require the facility to develop comprehensive corrective action plans addressing each identified deficiency. This includes retraining staff on proper medication administration, implementing enhanced monitoring systems, and establishing quality assurance processes to prevent future violations.
Federal surveyors will conduct follow-up inspections to verify that corrections have been implemented and sustained. Continued violations could result in enforcement actions including fines or loss of Medicare/Medicaid certification.
The facility must demonstrate concrete improvements in medication administration practices, safety device management, and overall quality assurance to regain compliance with federal standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Auburn Rehab & Health Center from 2025-04-21 including all violations, facility responses, and corrective action plans.
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