Sea-Crest Health Care Center, a Brooklyn based nursing home, was cited by the Department of Health in March of this year for two areas of deficiency. Both of these areas of sub-standard care involved medicinal distribution. More specifically, the facility failed to provide drugs and biologicals, and failed to keep residents free from significant medical errors. These citations by the Department of Health are in reference to an incident involving a single resident.
Pursuant to Section 483.60(a), (b) of the CFR, a facility must provide both routine and emergency drugs and biologicals to its residents. In order to do this, the facility “must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility.” In the case of Sea-Crest, the nursing home employed an outside vendor pharmacist. This pharmacist, and the facility itself, did not ensure that a prescribed anti-psychotic was ordered and provided to a resident. Sea-Crest itself did not provide the pharmacy with necessary laboratory work that the vendor would need in order to actually dispense and provide this anti-psychotic to the facility. The vendor, for its part, did not consult with the facility to determine the cause of the missing lab results. In a subsequent conversation between the DOH and the vendor pharmacy, the vendor indicated that it would be implementing new policies and procedures with respect to laboratory work, although the DOH report does not specify just what these additional procedures will be.
Regarding the same incident, the CFR mandates that a facility must ensure that residents are free from significant medication errors. The incident documented here by the DOH took place over a period of eight months. Failure to provide a resident with a prescribed anti-psychotic for eight months certainly qualifies as a “significant” medication error.
Fortunately for the resident, the Department of Health report indicates that this medication did not result in any actual harm to the resident. It did provide the potential for more than minimal harm, however. Perhaps this finding of deficiency by the DOH will lead to more stringent policies, and adherence to these policies, in the future for Sea-Crest.
The full report by the Department of Health can be accessed here.