Evan Terrace: Feeding Tube Error Causes Formula Leak - OR
Staff 9 admitted she mistakenly set Resident 2's feeding tube to deliver formula at 300 milliliters per hour during her shift on July 28....
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Staff 9 admitted she mistakenly set Resident 2's feeding tube to deliver formula at 300 milliliters per hour during her shift on July 28....
The facility had transcribed the resident's Finasteride prescription incorrectly from his hospital discharge summary....
The incident at Rehabilitation Center of Hampton came to light during a November 2025 complaint investigation....
Federal inspectors found the medication violations at Wedgewood Healthcare Center during a November complaint investigation....
On October 22 at 2:17 pm, inspectors watched Licensed Practical Nurse AA administer both Dilantin and the house supplement to R9 simultaneously....
The surveyor observed the unlocked cart against the nurses' station with no staff present....
Federal inspectors found that the administrator violated reporting requirements during their November investigation....
The Assistant Director of Nursing called the resident's wife and told her to pick up her husband immediately....
Federal inspectors who visited the facility in November found the resident's complaint was accurate....
Both residents had dementia and required physical help with bathing....
Resident #9 had been living at the 39-bed facility since his admission earlier this year....
The September 3 incident between the female resident and a male resident left her with a small cut on her lip....
Instead, nurses working from an incomplete fax never entered the medication into the system....
She told inspectors during a November 18 interview that she realized the error after the wrong medication had been infusing for less than five minutes....
The resident told inspectors on September 29, 2025 that staff had been withholding her medication because her blood pressure was low....
Then comparing those requirements against the actual food delivered....
Enhanced barrier precautions are implemented for residents at higher risk of infection transmission....
Federal inspectors observed the violation during a complaint investigation at the 58-bed facility....
The violation was classified as immediate jeopardy to resident health or safety, the most serious category of nursing home deficiency....
The incident occurred at Wright Rehabilitation and Healthcare Center on November 11, when Resident #10 complained of being cold during the evening smoke break....