LUCEDALE, MS - Federal inspectors found that George Regional Health & Rehab Center violated critical medication safety and infection control standards, placing residents at risk through improper administration of prescription drugs via feeding tubes and inadequate disinfection of shared medical equipment.
Dangerous Medication Mixing Puts Residents at Risk
The most serious violation involved the facility's practice of mixing multiple medications together before administering them through feeding tubes, directly contradicting manufacturer instructions and professional safety standards. During an inspection on April 30, 2025, surveyors observed a Licensed Practical Nurse combining four different medications - including two that should never be crushed - in a single cup before giving them to a resident through a PEG tube.
The medications involved included aripiprazole (Abilify), an antipsychotic medication, and lansoprazole (Prevacid), a proton pump inhibitor used for acid reflux. Both drugs carry specific manufacturer warnings against crushing due to their special formulations. Aripiprazole tablets are designed with controlled-release properties that can be compromised when crushed, potentially leading to dangerous fluctuations in blood levels. Lansoprazole contains enteric coating that protects the active ingredient from stomach acid - crushing destroys this protective barrier and can render the medication ineffective.
The facility had implemented a blanket physician's order allowing staff to "crush all non-liquid meds together and mix together for administration" for residents with feeding tubes. However, the inspection revealed no evidence of individualized assessments or pharmacy reviews to evaluate the safety of this practice for specific residents or medication combinations.
When interviewed, the Licensed Practical Nurse admitted she "had never checked for compatibility or consulted a pharmacist to ensure it was safe" to combine medications. The Director of Nursing acknowledged that "crushing and combining medications without checking for compatibility could cause problems" but confirmed the practice continued under physician orders.
Medical Consequences of Improper Medication Administration
Mixing crushed medications creates significant medical risks that extend far beyond simple inconvenience. When medications are combined, they can interact with each other in unpredictable ways, forming new chemical compounds that may be toxic or ineffective. The practice also affects how drugs are absorbed into the bloodstream, potentially causing dangerous peaks and valleys in medication levels.
For residents receiving multiple medications, these interactions can be life-threatening. Crushing extended-release formulations can cause an immediate release of the entire dose, potentially leading to overdose symptoms. Conversely, destroying protective coatings on acid-sensitive medications can result in therapeutic failure, leaving conditions untreated.
The Institute for Safe Medication Practices specifically warns against mixing multiple medications together, stating this can "create a new unknown entity with an unpredictable release and bioavailability." Professional standards require each medication to be prepared separately, administered individually, and the feeding tube flushed with at least 15 milliliters of water between each drug.
The facility's consultant pharmacist confirmed she had "explained to the nurses that safe practice standards for administering medication via PEG require medications to be given individually" and that "combining crushed medications can lead to pharmacokinetic changes and tube blockage, especially in high-risk residents."
Infection Control Breakdown Risks Disease Transmission
A second major violation involved improper disinfection of blood glucose monitoring equipment shared between residents. Inspectors observed a nurse using a glucose meter on a diabetic resident but failing to follow manufacturer guidelines for cleaning the device afterward.
The nurse wiped the glucometer for only 10 seconds with a disinfectant cloth, despite facility policy and manufacturer instructions requiring the surface to remain wet with disinfectant for two full minutes to effectively kill bloodborne pathogens. This abbreviated cleaning process fails to eliminate viruses such as HIV, Hepatitis B, and Hepatitis C that can be transmitted through trace amounts of blood.
When questioned, the nurse stated she "was not familiar with the manufacturer's guidelines that required a two-minute contact time." The Director of Nursing confirmed that the glucometer was shared among residents and acknowledged that "failure to cleanse it properly could lead to the transmission of blood borne diseases."
Blood glucose monitors present particular infection risks because they come into contact with blood during normal use. Even microscopic amounts of contaminated blood remaining on the device can transmit serious infections to subsequent users. The two-minute contact time is not arbitrary - it represents the minimum time required for the disinfectant to penetrate and destroy viral particles and bacteria.
Systemic Failures in Safety Protocols
These violations reveal broader problems with the facility's approach to resident safety. The medication administration issues stem from a concerning disconnect between different levels of staff and administration. While the Medical Director stated he "expects the pharmacy to review medications and check for compatibility," he admitted he "did not know staff were combining all medications for PEG administration."
This knowledge gap represents a fundamental breakdown in communication and oversight. The facility's own policies clearly stated that medications should not be crushed if they carry "do not crush" instructions and that "physician or practitioner documentation will be provided in the medical record stating the medical rational for crushing a medication against a manufacturer's instructions." However, no such documentation existed for the resident observed receiving improperly crushed medications.
Similarly, the infection control failure occurred despite the facility having clear written policies requiring proper disinfection procedures. The disconnect between policy and practice suggests inadequate training, supervision, or both.
Industry Standards and Regulatory Requirements
Federal regulations require nursing homes to ensure residents receive medications "in accordance with the orders of the prescriber" and to "store, prepare, distribute, and administer drugs and biologicals in accordance with professional standards of practice." The observed practices violated both requirements.
Professional medication administration standards, established by organizations like the Institute for Safe Medication Practices, are not suggestions but evidence-based protocols designed to prevent medication errors that can cause serious harm or death. The facility's blanket approach to medication crushing ignored these standards and the individual needs of residents.
For infection control, Centers for Disease Control and Prevention guidelines require healthcare facilities to properly clean and disinfect all reusable medical equipment between patients. The abbreviated disinfection process observed at the facility falls well short of these requirements and creates unnecessary infection risks.
Additional Issues Identified
Beyond these major violations, the inspection documented the facility's failure to maintain proper documentation and oversight systems. The absence of individualized medication reviews for residents with feeding tubes represents a missed opportunity to identify potentially dangerous drug combinations before they occur.
The facility's reliance on standing orders without proper clinical assessment violates the principle of individualized care that forms the foundation of nursing home regulations. Each resident's medication regimen should be evaluated based on their specific medical conditions, other medications, and individual risk factors.
The inspection found that staff training on both medication administration and infection control procedures was insufficient, with frontline nurses unaware of basic safety requirements. This suggests broader problems with the facility's education and competency programs.
Federal inspectors classified both violations as having caused "minimal harm or potential for actual harm" to residents, but noted they affected multiple residents and represented ongoing systematic problems rather than isolated incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for George Regional Health & Rehab Center from 2025-05-01 including all violations, facility responses, and corrective action plans.
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