"The LVN who opened the insulin pen should have labelled the insulin pen with date opened and expiration date," the nurse told inspectors during an 8:05 a.m.
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The infection control failures left families, staff and community members unaware of the potential exposure risk.
The nurse explained that Resident 1 had the right to watch television.
to give him his noon medication.
The incident occurred around 9:30 pm when Resident #1 entered Resident #2's room to visit his friend, who was Resident #2's roommate.
The registered nurse cleaned the sacral wound with Dakins solution, packed it with sponge material, and attached wound vacuum tubing.
The locking mechanism was protruding outward, clearly visible to anyone passing by.
CNA J was pushing the sit-to-stand transfer chair near the nurses' station on November 17 when an inspector spotted the filthy condition.
The incident at Harker Heights Nursing & Rehabilitation unfolded in late September when staff relocated Resident #1 without the family present.
She worked the overnight shift on the 200 hallway, where residents lived with broken furniture, cracked lights, and bugs crawling on them.
The documentation gap becomes more troubling when viewed against the resident's medication regimen.
The facility's own policy requires "NO SMOKING" signs outside every room where oxygen is in use.