Nursing Home News — Page 607

During the initial tour on March 10, investigators found an unlocked cart on the 300 hallway containing five opened, undated insulin pens.

Pneumonia poses a particularly serious threat to nursing home residents, who are among the most vulnerable populations for severe respiratory infections.

The citation followed documented incidents involving a resident who managed to leave the facility on multiple occasions due to systemic security breakdowns.

The case reveals a cascade of clinical failures that allowed a minor injury to worsen significantly.

In a separate incident involving a resident with leg wounds, the nurse practitioner again demonstrated poor hand hygiene practices.

On January 9, inspectors observed a nurse performing complex respiratory care while failing to follow basic contamination prevention protocols.

## Medication Management Failures The inspection uncovered significant concerns regarding medication administration and oversight at the facility.

This violation occurred despite facility policies mandating proper personal protective equipment during high-contact care situations.

Physician orders specifically required the IV access site to be flushed with 10 ml of normal saline solution before and after each medication administration.

Blood sugar levels above 350 mg/dL represent a medical emergency that can lead to diabetic ketoacidosis, a life-threatening condition.

The deficiency affected residents with terminal diagnoses including stroke and end-stage chronic obstructive pulmonary disease.

The attending nurse failed to wear protective gear required by EBP protocols and committed multiple contamination risks during the dressing change procedure.