Articles Posted in Infection

The Emerald Peek Rehabilitation and Nursing Center received 31 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Peekskill nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing did not provide treatment and services of a degree adequate to ensure prevention and/or healing of pressure ulcers. Section 483.25 of the Federal Code requires nursing home facilities to offer residents “care, consistent with professional standards of practice, to prevent pressure ulcers” from developing and to heal existing pressure ulcers. A January 2019 citation found “no evidence” that when a resident developed a pressure ulcer, the facility undertook actions to get rid of risk factors connected to pressure ulcer development. In response to the citation, the facility implemented a plan of correction that included weekly risk assessment and intervention audits to ensure the proper execution of preventative measures for pressure ulcer development.

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Hamilton Park Nursing and Rehabilitation Center received 9 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. The Brooklyn nursing home’s citations resulted from a total of two inspections by state surveyors, in November 2016 and May 2018. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to care for prevent pressure ulcers and bedsores. Under Section 483.25(c) of the Federal Code, nursing homes must provide a level of care that prevents residents who enter without pressure sores from developing them unless their condition renders such unavoidable; and that residents suffering from pressure sores must receive necessary and adequate care. A November 2016 citation describes the failure by Hamilton Park Nursing & Rehabilitation Center to follow orders to provide a resident with “dry protective dressing on a sacral ulcer.” The resident was admitted to the facility with three unhealed pressure ulcers, according to the citation, and a physician ordered that one of them be treated in part with dry protective dressing. An inspector observed the resident without the required dressing, and spoke to a staff nurse, who “confirmed that she was not informed that the necessary dressing was missing and needed to be replaced.” The inspector determined in an interview with a Certified Nursing Assistant that the CNA had forgotten to inform the nurse of such.

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Bedford Center for Nursing and Rehabilitation received 36 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. It also received a Department of Health fine of $6,000, in September 2011, over alleged violations of sections of the health code relating to the investigation and reporting of allegations, accidents and supervision, and administrative practices. The Brooklyn nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not provide an adequate level of treatment and services to prevent and heal pressure ulcers. Section 483.25 of the Federal Code states that nursing homes must provide residents with “care, consistent with professional standards of practice, to prevent pressure ulcers.” A November 2018 citation found that Bedford Center for Nursing and Rehabilitation failed to ensure that a resident received adequate care to prevent pressure ulcers. An inspector specifically observed on multiple instances that the resident was in their bed without wearing heel booties. According to the citation, the resident was at “very high risk” for skin breakdown, and medical orders directed that heel booties be applied while the resident is in bed. In interviews, both a Registered Nurse and a Licensed Practical Nurse stated that they were not certain why the resident was not wearing the necessary assistive devices while in bed.

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North Westchester Restorative Therapy and Nursing Center received 14 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Mohegan Lake nursing home’s citations resulted from a total of three inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure residents a medication error rate below 5%. Under Section 483.45 of the Federal Code, nursing homes must maintain medication error rates that do not reach or exceed 5%. A January 2019 citation states that during a recertification survey, North Westchester Restorative Therapy and Nursing Center experienced a medication error rate of 6.45%, attributing this rate to two instances of medication errors. According to the citation, an inspector observed a Licensed Practical Nurse providing a resident with an inhaler and instructing her to “put the inhaler and her lips and take a deep breath in.” The nurse then provided the resident with another inhaler and gave the same instructions. The citation states that the manufacturer’s instructions for the inhalers in question state in part that users should: “before you inhale, breathe out (exhale) through your mouth and push out as much air from your lungs as you can. Hold your breath for about 10 seconds, or for as long as you can.” The nurse in question stated that she was unaware of this requirement, or that it was a standard practice “to wait approximately 10 minutes in between administration of 2 different inhalers.”

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Sans Souci Rehabilitation and Nursing Center received 15 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 29, 2019. The Yonkers nursing home’s citations resulted from a total of three inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not maintain sufficiently low medication error rates. Section 483.45 of the Federal Code states that nursing homes must maintain medication error rates that do not reach or exceed five percent. An August 2018 citation states that errors connected to two residents observed during a medication pass resulted in an error rate of 9.6%. An inspector specifically observed a nurse provide a resident with a multiple vitamin tablet instead of a multiple mineral tablet, and observed another nurse administer a resident with one off of an inhaler rather than two puffs, and administer that resident with an artificial tear solution with a strength that was not the same strength ordered by the physician. The citation states that these errors resulted in the “potential to cause more than minimal harm” to residents.

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The Grove at Valhalla Rehabilitation and Nursing Center received 27 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 29, 2019. The Valhalla nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately implement an infection prevent and control system. Under Section 483.80 of the Federal Code, nursing home facilities must create and maintain infection prevention and control protocols that are “designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” An August 2018 citation found that the facility did not properly ensure its staff undertook adequate hand hygiene measures “to prevent cross contamination and the spread of infection” in connection to one resident. The citation states specifically that during a wound observation of the resident, who was at risk of developing a pressure ulcer, an inspector observed a Licensed Practical Nurse “his bare hands to reposition the resident in bed, in addition to pulling the bedside curtain to maintain privacy.” Then, without sanitizing his hands, the nurse in question put on a pair of of gloves with which he opened a saline solution bottle, poured the solution on gauze pads, and cleaned the resident’s wound. According to the citation, the nurse continued wearing “the soiled gloves” as he went on to perform several other activities that included touching the wound. The citation states that this conduct had the “potential to cause more than minimal harm.”

2. The nursing home did not properly implement its abuse and neglect investigation and reporting policies. Section 483.12 of the Federal Code requires nursing homes to develop and implement policies and procedures that prohibit and prevent abuse and neglect, and that provide for the investigation of abuse and neglect allegations. A November 2018 citation found that the nursing home failed to thoroughly investigate a resident’s unwitnessed fall, and to timely report the incident to state authorities in order to rule out the possibility of abuse, neglect, or mistreatment. The citation states further that the nursing home failed to report and investigate a second fall sustained by the resident. In response to the citation, the nursing home initiated an investigation into one of the incidents, and stated its intention to report the incident and the investigation’s results to state health authorities.

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Beth Abraham Center for Rehabilitation and Nursing received 30 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. The Bronx nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not properly ensure the prevention and control of infection. Under Section 483.80 of the Federal Code, nursing home facilities “must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” During a May 2019 inspection, a surveyor observed a Licensed Practical Nurse “performing blood pressure monitoring for 3 residents without cleaning the blood pressure cuff between residents”; another LPN administering eye drop medication without maintaining “proper hand hygiene”; and a third LPN failing to maintain proper hand hygiene while completing a wound care observation.

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Fieldston Lodge Care Center received 38 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. That figure is six greater than the statewide average of 32 citations. The Bronx nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not take adequate measures to prevent and control infection. Section 483.80 of the Federal Code stipulates that nursing home facilities “must establish and maintain an infection prevention and control program… to help prevent the development and transmission of communicable diseases and infections.” A July 2019 citation found that Fieldston Lodge Care Center failed to properly implement its disease prevention guidelines by neglecting to properly clean poles for hanging gastrostomy tube feeding, and by allowing oxygen tubing to run along the floor in spite of protocol requiring that it be maintained off the floor. A state inspector found that this lapse had the “potential to cause more than minimal harm.”

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The Citadel Rehab and Nursing Center at Kingsbridge received 19 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 14, 2019. Those citations include two that were found to cause immediate jeopardy to resident health, and one that authorities say reflected “a severe, systemic deficiency.” The Bronx nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure it provided an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide residents with an environment as free as possible from accident hazards, and with proper supervision and assistive devices to prevent accidents. An August 2016 citation states that an inspector observed more than 50 beds with siderails whose measurements “exceeded the FDA recommendation that spaces between the bed siderail bars should be no larger than 4 3/4 inches.” While the Department of Health inspector found that this deficiency had so far not resulted in actual harm, it had “the potential for more than minimal harm that was immediate jeopardy and substandard quality of care.”

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The New York Health Department confirmed an antibiotic-resistant ‘superbug’ was found at Palm Gardens Center for Nursing and Rehabilitation in Brooklyn. State health officials say that Candida auris, a highly contagious, drug-resistant fungus infected 38 patients at the Brooklyn nursing home. Since arriving in the United States in 2015, 800 Americans have been diagnosed with C. auris. According to public health officials, the victims of this contagious disease are typically elderly and more than half die from the disease within 90 days.

Public health officials believe that Maria Davila may have brought the ‘super bug’ into the nursing home. After arriving at the nursing home several years ago, Davila suffered from recurrent bacterial infections – which were treated with heavy doses of powerful antibiotics. During those trips in-and-out of the hospital, bacteria that responded to the medication was eradicated. C. Auris, however, is resistant to antibiotics and therefore followed Davila back to the nursing home. The contagious disease then spread to 38 other residents.

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