Queens (NYC) Nursing Home Receives $20,000 Fine After Medication Error

The Department of Health fined Queens Nassau Rehabilitation and Nursing Center $20,000 resulting from a certification survey from March 19, 2010. The two main health inspection violations during this inspection involve failure to provide necessary care for the highest practicable well-being, and the responsibilities of a physician during visits.

42 CFR 483.40(b) states that the “physician must review the resident’s total program of care, including medications and treatments, at each visit.” Section 483.25 dictates that “each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.” Both of these violations in the case of Queens Nassau stem from an incident involving the same resident.

pills.jpgThe incident in question, which the DOH reports resulted in actual harm, centers around a medication error. The treating physician of the patient ordered a hold on the resident’s Dilantin medication. However, the physician failed to review the man’s total care program. Additionally, the facility did not properly monitor the resident’s blood. Essentially, the staff did not follow physician’s orders, and the physician did not catch the mistake. Twice during a three month span, the patient required transfer to a nearby hospital with Dilantin toxicity of the blood after staff discovered him unsteady with unexplained lacerations.

Miscommunication and inconsistent record keeping can often lead to medication errors such as the one described here. During the inquiry, the physician informed the DOH that he had gone on vacation during the period of the error, and was unaware of the mix-up until the resident was taken to the hospital. Accurate communication between the physician and the hospital staff is vital for the health and well-being of the facility’s residents. At some point during this resident’s stay, this communication broke down, leading to the actual harm described within the DOH report.

Additional violations from this inspection, including life safety code violations, can be located here.

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