Midsouth Health & Rehabilitation Center nursing home was forced to close after it was discovered that staff did not know they were required to disinfect a blood-testing device after using it on an HIV-positive patient, potentially exposing others to the incurable infection. According to documents from the Tennessee Board for Licensing Health Care Facilities, the nursing home put patients in “serious jeopardy” of contracting HIV by failing to disinfect a blood glucose monitor, or “glucometer,” between treatment of patients. The tool is designed to be used on multiple patients, but is supposed to be cleaned with disinfectant wipes and allowed to dry for 5 minutes between every use. Regardless, at least two nurses failed to wipe or clean the tool between patients, the state records say. At one point, the error occurred in direct view of an inspector who was there to assess the facility.
“When confronted, the (nurse) admitted she did not clean the glucometer after using it on the HIV-positive patient,” state records say. “When questioned further, neither (the nurse) nor her supervisor knew whether the glucometer was to be cleaned with alcohol or bacterial wipes.”
The facility shut down in May after losing its Medicare certification because of a failure to “meet basic health and safety requirements”. State records also reveal a list of other violations: Some residents repeatedly escaped, and it took the nursing home hours to notice they were gone. Others too weak to bathe themselves were left filthy, receiving only one shower a month.
The nursing home also struggled to keep track of its patients, the government records show. At least four “cognitively impaired” patients escaped the facility this year, sometimes more than once, and it sometimes took nursing home staff as long as seven hours to notice they were missing. One patient with brain damage who used a wheelchair was known to wheel himself across a four-lane highway to buy alcohol at a gas station, state records say. Another patient, who also used a wheelchair, escaped in March, then was found two days later at a hospital in Kentucky.
The nursing home also failed to bathe patients regularly. One patient, who suffered from several serious diseases and was too weak to wash herself, was showered only once a month in February and March, according to the state documents. Patients records indicted she was supposed to be showered three times a week.