Thomasville Care Center: Critical Lab Failure Led to Hospitalization - GA
THOMASVILLE, GA - A serious breakdown in medical oversight at Thomasville Care Center resulted in a resident's emergency hospitalization after the facility failed to follow physician orders for routine blood testing, according to a federal inspection report.
Laboratory Testing Breakdown Results in Emergency Hospitalization
The most severe violation occurred when facility staff failed to obtain physician-ordered blood tests for a resident in March and June 2023. The oversight went undetected until September 2023, when blood work finally revealed the resident had a critically low hemoglobin level of 5.9 g/dl - far below the normal range of 13.5-17.5 g/dl.
The resident required immediate emergency transportation and received two units of blood at the hospital after being diagnosed with iron deficiency anemia. Medical records show the physician had specifically ordered complete blood count tests every three months in March, June, September, and December.
The facility's Unit Manager confirmed during interviews that the ordered blood tests for March and June 2023 were never completed, and no results could be located in either the electronic laboratory system or the resident's medical record. This represents a significant failure in the facility's laboratory tracking and follow-up procedures.
Hemoglobin levels below 6 g/dl are considered life-threatening and require immediate medical intervention. Normal hemoglobin levels help transport oxygen throughout the body, and severe deficiencies can lead to organ damage, heart problems, and other serious complications.
Multiple Safety Violations Documented
Beyond the laboratory testing failure, federal inspectors documented several other concerning safety violations during their August 2024 visit.
Oxygen Safety Hazards
An unsecured oxygen cylinder was found sitting freely on the floor of a resident's room, creating a potential explosion hazard. The Licensed Practical Nurse who removed the cylinder confirmed that if tipped over, the tank "could result in an explosion injuring residents and others."
The facility's Oxygen Concentrator policy explicitly requires proper storage and securing of oxygen equipment. Additionally, the same resident was receiving oxygen at incorrect flow rates - 1.5 liters per minute instead of the physician-ordered 2-4 liters per minute. No warning signs were posted on the resident's door to alert staff and visitors to oxygen use in the room.
Catheter Care Deficiencies
Inspectors observed multiple instances of improper catheter positioning that could obstruct urine flow and increase infection risk. A resident with severe cognitive impairment was repeatedly found sitting on catheter tubing or with the collection bag positioned above waist level.
The facility lacked physician orders for catheter monitoring and care. Nurses acknowledged the importance of proper positioning to prevent urinary tract infections and sepsis, particularly concerning given the resident's history of both conditions.
Dialysis Care Coordination Failures
The facility failed to provide adequate monitoring for a resident receiving hemodialysis three times weekly. Inspectors found missing physician orders for dialysis access site care and incomplete communication records with the dialysis center.
Dialysis communication sheets were missing or incomplete for periods spanning from September 2023 through August 2024. Proper coordination between nursing facilities and dialysis centers is essential for preventing complications such as access site infections, blood clots, and other serious medical issues.
The facility's hemodialysis policy requires ongoing assessment and monitoring for complications before and after treatments, along with consistent communication with the dialysis facility.
Staffing and Food Safety Concerns
The inspection revealed the facility failed to maintain required registered nurse coverage for eight full hours within 24-hour periods on seven separate days between January and March 2024. Federal regulations mandate continuous RN supervision to ensure proper medical oversight.
Food safety violations included improperly labeled and expired items in kitchen storage areas. Inspectors found unlabeled tuna salad, expired fried onions, and an ice machine with significant lime and calcium buildup that had not received quarterly cleaning.
Kitchen staff used incorrect portion sizes for residents requiring pureed diets, potentially compromising nutritional adequacy. The facility's recipes called for specific scoop sizes to ensure residents received appropriate protein portions, but staff were using smaller measures.
Regulatory Requirements and Standards
Federal nursing home regulations require facilities to provide physician-ordered laboratory services promptly and maintain accurate records of all test results. Failure to obtain ordered tests can delay critical medical interventions and compromise resident safety.
Oxygen therapy must be administered according to physician specifications, with proper storage and safety protocols followed at all times. Catheter care requires specific positioning techniques and physician oversight to prevent complications.
Facilities must maintain registered nurse coverage for a minimum of eight hours within each 24-hour period to ensure adequate clinical supervision and emergency response capabilities.
The inspection findings represent violations of multiple federal regulations governing nursing home operations, including requirements for laboratory services, respiratory care, accident prevention, and professional nursing oversight.
Facility Response
Thomasville Care Center's Administrator acknowledged awareness of the staffing discrepancies and reported discussing resolution strategies with corporate leadership. The facility's nurses indicated they would implement additional training on catheter positioning and dialysis care coordination.
Kitchen staff received immediate retraining on proper food labeling and portion control procedures. The ice machine underwent cleaning during the inspection period.
The complete inspection report provides additional details about corrective measures and facility responses to the documented violations. Families considering care options or with loved ones at the facility may wish to review the full federal inspection findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thomasville Health & Rehab, LLC from 2024-08-11 including all violations, facility responses, and corrective action plans.
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