Instead, nurses documented giving the medication while recording dangerous vital signs.
Nursing Home News — Page 279
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The laundry supervisor didn't know manufacturer guidelines for washing the fabric slings that support residents during transfers.
The violations put residents at risk of receiving ineffective or potentially harmful treatments.
The resident, who has mild intellectual disabilities and cannot make medical decisions, had been wearing the bracelets when staff noticed the odor on March 20.
The violations occurred in plain sight of infection control warnings.
Federal inspectors discovered the oversight during a May inspection when they reviewed the facility's Referral Form for Consultant Dietician.
Resident #3 told inspectors on May 20: "It's hot, it's hot, I am sweating.
The resident had been placed on enhanced barrier precautions since March 25 due to a multidrug-resistant organism infection.
The physician had ordered staff to "rotate injection site" with each dose.
The resident had been picked up from dialysis at 4:30 p.m.
The facility suspended the aide within hours but declared the investigation complete after four days without interviewing key staff or the resident's roommate.
The March 21 incident began around 6:45 a.m.