WAREHAM, MA - Federal inspectors documented serious violations at Tremont Health Care Center during an August 2024 inspection, identifying multiple failures in medication management, patient transfers, and infection control that created potential safety risks for vulnerable residents.
Missing Orders Put Residents at Risk During Hospital Transfers
The facility failed to obtain proper physician orders before transferring four different residents to hospitals following medical emergencies, creating potentially dangerous gaps in medical oversight. State nursing practice guidelines require licensed nurses to verify and implement physician orders for all patient care decisions, including emergency transfers.
In one case documented June 28, 2024, Resident #36, who had Alzheimer's disease and a history of repeated falls, was found on the floor and transferred to the hospital via 911 after staff called the resident's healthcare proxy and physician. However, inspectors found no physician's order authorizing the transfer in the medical record. When questioned, the nurse on duty said she was "not sure if a physician's order is needed when a resident is transferred to the hospital," despite facility policy requiring such orders.
Similar violations occurred with three other residents transferred between March and June 2024. The Assistant Director of Nursing confirmed that physician orders should be documented when residents are transferred to hospitals, yet records consistently showed these critical authorizations were missing.
This pattern represents a fundamental breakdown in medical protocols. Hospital transfers require physician oversight to ensure appropriate medical decision-making and continuity of care. Without proper orders, facilities cannot demonstrate that transfers were medically necessary or that receiving hospitals received adequate information about the resident's condition and treatment needs.
Dangerous Medication Administration Errors
The facility demonstrated serious deficiencies in medication safety when a nurse administered blood pressure medication without checking vital signs as required by physician orders. On July 31, 2024, inspectors observed Nurse #1 giving Metoprolol Tartrate, a heart and blood pressure medication, to Resident #42 without first checking the resident's blood pressure and pulse.
The physician's order specifically required withholding the medication if systolic blood pressure dropped below 110, diastolic pressure below 60, or heart rate below 60 - parameters that can only be determined by taking vital signs before administration. Metoprolol can cause dangerous drops in blood pressure and heart rate, making pre-administration monitoring essential for patient safety.
When questioned, the nurse admitted she had not checked the resident's vital signs prior to giving the medication and acknowledged she should have done so. This violation demonstrates how failure to follow medication protocols can expose residents to serious cardiovascular risks, particularly given that nursing home residents often have multiple medical conditions that increase their vulnerability to medication-related complications.
Complex Medical Device Mismanagement
Perhaps most concerning was the facility's handling of a PICC line (peripherally inserted central catheter) for Resident #30, who had chronic kidney failure and bilateral nephrostomy tubes. The resident was readmitted from the hospital in March 2024 with a PICC line for intravenous antibiotic therapy to treat severe sepsis.
Professional standards and the facility's own policy require PICC lines to be flushed with saline solution before and after each medication administration to prevent blood clots, infection, and catheter blockage. The physician ordered PICC line flushing "every shift," but failed to provide specific orders for the critical before-and-after medication flushes required by medical standards.
Medical records showed the resident received two different IV antibiotics (Ertapenem and Vancomycin) at 2:00 PM and 3:00 PM respectively, but contained no physician orders for the mandatory pre- and post-medication flushes. A nurse indicated on documentation that these flushes were performed by marking "X" symbols rather than proper initials, creating confusion about whether the procedures actually occurred.
PICC lines carry significant infection and clotting risks when not properly maintained. The resident was transferred back to the hospital just one day later due to a change in condition, and the PICC line was subsequently removed during that hospitalization.
Mental Health Care Coordination Failures
The facility failed to properly coordinate psychiatric care for two residents with serious mental health conditions. Resident #34, who had depression, anxiety, and schizoaffective disorder, expressed suicidal thoughts to staff in July 2024. A nurse practitioner evaluated the resident and recommended starting Remeron (an antidepressant) for insomnia and depression, but this recommendation was never implemented.
The resident's healthcare proxy was not informed of either the suicidal ideation incident or the medication recommendation. When contacted by inspectors, the proxy said she was unaware of any recent mental health concerns and was working with the facility to reduce the resident's medications, not add new ones. The resident reported sleeping difficulties due to noise levels on the unit.
Similarly, Resident #9, who had major depressive disorder and paranoid personality disorder, had psychiatric medication adjustments recommended in July 2024 that were never communicated to the attending physician for implementation. The resident continued exhibiting behavioral symptoms including crying and arguing with staff and roommates while the recommended treatments remained unaddressed.
These coordination failures demonstrate how communication breakdowns in psychiatric care can leave vulnerable residents without appropriate treatment for serious mental health conditions.
Additional Issues Identified
Inspectors documented numerous other violations including improper medication storage with carts left unlocked and medications found at residents' bedsides without authorization. Food safety violations included unlabeled and expired items in kitchens and storage areas, as well as unsanitary conditions in food preparation areas.
During a COVID-19 outbreak, staff failed to follow proper testing protocols by reading test results before the required 15-minute waiting period and improperly removing personal protective equipment. The facility also failed to complete required safety assessments, including quarterly smoking evaluations for residents who use tobacco products.
The facility's assessment tool, used to determine staffing and resource needs, contained significant inaccuracies including blank fields for numerous medical conditions the facility regularly treats and incorrect identification of management systems.
These violations collectively demonstrate systemic deficiencies in basic safety protocols that protect nursing home residents, who as a population face heightened vulnerability to medical errors, infections, and complications from inadequate care coordination.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tremont Health Care Center from 2024-08-05 including all violations, facility responses, and corrective action plans.
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