Cambridge Post Acute Care Center

Ensure that residents are free from significant medication errors.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of the facility's policy titled, Medication Delivery Expectations-Nurses, the facility failed to keep one of six residents (R) (RB) free from significant medication error.Findings include:

Review of the facility's policy titled Medication Delivery Expectations-Nurses last revised June 2025 documented under Protocol: .8.

Notify the physician if medication will be given late or obtain an alternative order or different start time, if appropriate.

Review of the electronic medical record (EMR) revealed RB was admitted with diagnoses of but not limited to intraspinal abscess and granuloma, infection following a procedure, candidiasis, chronic obstructive pulmonary disease (COPD), asthma, depression, and muscle weakness.Review of RB's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficits.

Review of the care plans for RB revealed the care plan was updated 8/16/2025: readmission on [DATE] with s/p (status post) transfusion status. 8/16/2025 readmission with DX (diagnosis) of extraspinal abscess and granuloma, infection following procedure.

Focus: Resident is receiving antibiotic/fluids intravenously via PICC related to sepsis (life-threatening reaction to an infection). readmission on [DATE] with IV antibiotic therapy via PICC (peripherally inserted central catheter) line for infection with status post spinal abscess of C2-C4 (cervical vertebrae) with s/p (status post) surgical procedure. 8/16/2025 readmission IV antibiotic therapy continue.

Outcome: Resident will have a resolution in infection through next review date.

Interventions: Administer Intravenous fluids as ordered per MD (medical doctor).

Change IV site per facility protocol.

Dressing changes to IV site per facility protocol.

Monitor IV site for s/s (signs/symptoms) of infection.

Monitor/observe for adverse reaction to medication and report abnormal findings to MD/RP (responsible party)/Resident. PICC line maintenance care as ordered.

Review of the Physician's orders for RB revealed an order for Micafungin Sodium-NaCl sodium chloride) intravenous Solution 100-0.9 mg (milligram)/100 ml (milliliter)-% (percentage) use intravenously every 24 hours for antibiotic therapy until 10/05/2025 23:59.

Cefazolin Sodium injection solution reconstituted 2 GM (grams) Use 1 dose intravenously every eight hours for abscess to cervical spine until 10/6/2025.

Review of the Medication Administration Record (MAR) for September 2025 for RB revealed Cefazolin doses were missed on 9/18/2025 at 1400 (2:00 pm), and 2200 (10:00 pm), 9/19/2025 at 0600 (6:00 am), and 1400 (2:00 pm), and on 9/22/2025 the dose at 1400 was missed.

Number eight (8) was inserted in the MAR for these dates meaning the medication was not given.

Micafungin Sodium-NaCl Intravenous solution 100-0.9 mg/100 ml dose was missed on 9/18/2025 and 9/19/2025. An interview with Registered Nurse (RN) GG on 9/24/2025 at 11:37 am revealed when a PICC line came out, we just wait until the PICC is inserted to restart the antibiotic. An interview on 9/24/2025 at 11:45 with the Director of Nursing (DON) revealed her expectation when a PICC line was not usable for whatever reason was the nurse was to call the Doctor and request an alternative route for the medication, if there was no alternative, we got an order to reinsert.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cambridge Post Acute Care Center

2020 McGee Road Snellville, GA 30078

SUMMARY STATEMENT OF DEFICIENCIES

Observation of a dressing change for R15 on 9/24/2025 at 11:42 am, LPN AA entered R15's room to perform a dressing change. A sign for EBP precautions was posted on the door; however, LPN AA and Wound Tech II did not wear gowns prior to or during the procedure.

When treating the right hip wound, LPN AA removed the soiled packing but did not change her gloves before applying Dakin's solution to gauze and covering the wound with a new bordered gauze island dressing.

While still wearing the same contaminated gloves, she reached into her pocket to retrieve a marker to date the dressing and then returned the marker to her pocket without cleaning it.

The same practice was observed during the sacral dressing change, when she again retrieved the marker from her pocket while wearing contaminated gloves and then returned it to her pocket.

When changing the dressing on the left hip, LPN AA changed gloves after removing the soiled dressing from the right hip; however, hand hygiene was not performed after glove removal.

In an interview following the observation, the surveyor asked LPN AA why she wore a gown for one resident prior to a dressing change but did not wear one for R15. LPN AA stated she forgot to do it and acknowledged she ignored the EBP signage on the door, explaining that there were no PPE supply boxes or a cart at the doorway to remind her.

Wound tech II also confirmed that gowns should have been worn when providing high-contact care to the resident, but acknowledged they failed to do so.

In an interview with the Infection Preventionist (IP)/Staff Development Nurse on 9/24/2025 at 12:33 pm, she stated that staff were frequently educated on EBP and the use of gowns during high-contact care to residents with wounds or catheters, both to protect residents and to reduce the risk of infection.

In an interview with the Director of Nursing (DON) on 9/24/2025 at 12:35 pm, she stated her expectations were that staff consistently followed infection control practices, including frequent hand hygiene, sanitizing hands when changing gloves since glove changes do not substitute for hand hygiene, and adhering to EBP precautions for residents with wounds, central lines, or catheters.

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