GREENSBURG, PA - State health inspectors documented multiple violations at Westmoreland Manor nursing facility during a May 2025 inspection, including improper medication administration and failures to follow critical intravenous therapy protocols.
IV Line Protocol Failures Put Residents at Risk
During the inspection, investigators found that nursing staff at Westmoreland Manor failed to properly maintain intravenous catheters for two residents requiring critical antibiotic treatments. The violations centered on the facility's failure to flush PICC lines (peripherally-inserted central catheters) according to physician orders and established protocols.
Resident 77, who was receiving treatment for a urinary tract infection, had physician orders for 500 milligrams of Invanz antibiotic administered through a PICC line. However, medication administration records showed no documentation that staff flushed the IV line after antibiotic administration, despite facility policy requiring this critical step.
Similarly, Resident 207, who had recently undergone amputation of her left big toe and required IV antibiotics, received daily doses of Vancomycin from April 18-24, 2025. Physician orders specifically required the IV access site to be flushed with 10 ml of normal saline solution before and after each medication administration. Documentation revealed staff failed to perform these required flushes during any of the antibiotic administrations.
The Clinical Compliance Officer confirmed during interviews that proper flushing protocols were not followed for either resident, representing a significant departure from standard medical practice.
Medical Significance of IV Line Maintenance
PICC lines require meticulous care to prevent serious complications. Proper flushing serves multiple critical functions: it prevents blood clots from forming in the catheter, reduces the risk of medication incompatibilities, and helps maintain catheter patency (keeping the line open and functional).
When IV lines are not properly flushed, several dangerous complications can occur. Blood can back up into the catheter and form clots, potentially blocking the line entirely or breaking loose to cause embolisms. Medication residue can build up inside the catheter, creating a breeding ground for bacteria that can lead to bloodstream infections. These infections, known as central line-associated bloodstream infections (CLABSIs), can be life-threatening, particularly for elderly residents with compromised immune systems.
For residents requiring extended antibiotic therapy, maintaining proper IV access is essential for treatment success. A blocked or infected PICC line may require surgical removal and replacement, subjecting residents to additional medical procedures and interrupting their treatment regimen.
Medication Administration Errors Exceed Federal Standards
The inspection revealed that Westmoreland Manor's medication error rate reached 6.67 percent, exceeding the federal requirement that facilities maintain error rates below 5 percent. This violation was documented through direct observation of medication administration practices.
During observations on August 21, 2024, surveyors identified two medication errors among 30 administration opportunities. Resident 106 was prescribed 250 milligrams of calcium citrate twice daily for Vitamin D deficiency, but staff administered 950 milligrams instead - nearly four times the prescribed dose. The Licensed Practical Nurse confirmed during interviews that while the physician's order specified 250 mg, the pharmacy had dispensed 950 mg cards, and staff failed to catch the discrepancy.
Resident 147, who has multiple sclerosis and requires artificial tears for dry eyes, was prescribed two drops in each eye three times daily. However, nursing staff administered only one drop per eye. The Licensed Practical Nurse initially stated she had completed the administration correctly but later acknowledged the error when questioned.
Understanding Medication Error Implications
Medication errors in nursing homes can have serious consequences, particularly for elderly residents who may be more sensitive to dosing variations. Calcium supplementation errors can lead to kidney stones, constipation, and interference with the absorption of other essential medications. For residents with kidney disease, like Resident 106, excessive calcium intake can worsen renal function.
Under-dosing of eye medications may seem minor, but for residents with multiple sclerosis, proper eye care is crucial. The condition can affect vision, and inadequate treatment of dry eyes can lead to corneal damage and further vision complications.
Federal regulations require nursing facilities to implement systems that prevent medication errors through multiple safety checks. The "six rights" of medication administration - right resident, right drug, right dose, right time, right route, and right dosing form - form the foundation of safe medication practices. When facilities exceed the 5 percent error threshold, it indicates systemic problems with their medication management systems.
Systemic Issues in Clinical Care
The violations documented at Westmoreland Manor point to broader issues with clinical oversight and staff training. Both the IV line maintenance failures and medication errors suggest gaps in nursing staff education and supervision. Proper PICC line care requires specific training and consistent application of protocols, while medication administration errors often stem from inadequate checking procedures or workload pressures that compromise careful review.
The facility's own policies correctly outlined the requirements for IV catheter flushing, indicating that the violations resulted from implementation failures rather than inadequate written procedures. This disconnect between policy and practice suggests the need for enhanced staff training, better supervision, and stronger quality assurance measures.
Additional Issues Identified
Beyond the major violations, the inspection identified other areas of concern. The facility's management systems were cited for deficiencies, though specific details were not fully elaborated in the available documentation. These citations suggest potential issues with administrative oversight and quality management processes that may contribute to the clinical care problems observed.
The presence of multiple violation categories indicates that Westmoreland Manor faces challenges across different aspects of resident care and facility management. Addressing these issues will likely require comprehensive quality improvement efforts rather than isolated fixes to individual problems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westmoreland Manor from 2025-05-08 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.