Health Department: Low Staffing Levels Caused Medication Errors at Nursing Home

After conducting an investigation in April 2012, officials from the New York State Department of Health (DOH) concluded that the Mercy Living Center, a 60-bed facility located in Tupper Lake, New York, failed to employ enough nurses to administer medications to patients in a proper and timely manner. The DOH report stated, “The Administrator failed to have systems in place to ensure sufficient staffing was provided to ensure that the residents’ medications and treatment were administered as ordered by the physician.” The facility only employed one licensed practical nurse (LPN) per shift to administer medications and treatments to 40 residents. In some cases, patients required multiple visits per shift to receive numerous medications and treatment.

meds1.jpgOne LPN told a DOH investigator that she often failed to provide treatment to a resident who had a Stage II bedsore. In another instance, the DOH discovered that a resident did not receive 14 doses of his Parkinson’s disease medication over a period of 20 days. The LPN who was responsible for the missed doses admitted that it “happens a lot.” One patient suffering from COPD was prescribed nine medications which he was to receive every morning at 8:00 a.m. However, a DOH inspector observed that his medications were administered two hours late. The LPN who administered the late medication stated that she “gets to them when she can.”

Several nurses stated that they complained to supervisors and administrators on numerous occasions that they needed more help to provide adequate care for patients. However, supervisors would often nod and simply say, “I know. I know.” One supervisor told employees to “do the best you can.” As a result of DOH survey, the facility is now required to have two nurses per shift to administer treatments and medications. If a staff member cannot come to work, the Nurse Manager or the Director of Nursing will be required to work the shift.

DOH inspectors also cited the facility for failing to inform physicians of significant changes to patients’ statuses. For instance, one resident was diagnosed with dementia and psychosis. He had a history of making sexually inappropriate remarks towards staff members and residents. His care plan indicated that staff members needed to inform the physician if he exhibited any inappropriate behavior. Over a nine day period, numerous staff members noted that the resident’s behavior was sexually inappropriate. In one instance, he kept telling staff member and residents, “I just want to touch and kiss you.” In another instance, he was found kissing and groping a female resident. Staff members did not inform the physician of this behavior. Moreover, they did not file a report to begin an investigation into possible cases of

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