Articles Posted in Medication Errors

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A nursing home based in Syracuse, New York has received 57 health citations since 2017.

Van Duyn Center for Rehabilitation and Nursing has received 57 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on April 8, 2021. The facility has additionally received seven fines totaling $90,000 since 2008. The Syracuse nursing home’s citations resulted from a total of 15 surveys by state inspectors. The deficiencies they describe include the following: Continue reading

Wesley Gardens Corporation received 75 citations for violations of public health laws between 2017 and 2021, according to New York State Department of Health records accessed on April 1, 2021. The facility has also received three fines since 2016, totaling $16,000, over findings of health code violations. The Rochester nursing home’s citations resulted from a total of six inspections by state surveyors. The deficiencies they describe include the following:

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The nursing home in upstate New York has also received $16,000 in fines since 2016.

1. The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes must maintain medication error rates below five percent. An August 2019 citation found that Wesley Gardens Corporation failed to ensure such. The citation states specifically that while a resident’s physicians orders stated that their medications were to be administered at 9am, they were observed being administered at 11:10am. In an interview, the Licensed Practical Nurse who administered the medications stated that they were administered late because there was “only one nurse passing medications on the unit,” and that four other residents also received late medication administration. A plan of correction undertaken by the facility included the counseling of the LPN.

The Grand Rehabilitation and Nursing at Mohawk received 44 citations for violations of public health laws between 2017 and 2021, according to New York State Department of Health records accessed on April 1, 2021. The facility has also received three fines since 2019, totaling $22,000, over findings of health code violations. The Ilion nursing home’s citations resulted from a total of 10 inspections by state surveyors. The deficiencies they describe include the following:

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The nursing home in New York was also cited for medication errors.

1. The nursing home did not employ adequate measures to control infection. Section 483.80 of the Federal Code stipulates that nursing homes must help prevent the transmission of communicable diseases and infections by creating and upholding an infection control program. A December 2020 citation found that The Grand Rehabilitation and Nursing at Mohawk failed to ensure such. The citation states specifically that two Certified Nursing Aides “tested positive for COVID-19 and returned to work” before completing a 14-day quarantine and receiving negative PCR tests. Guidance at the time held that nursing home employees who test positive and remain asymptomatic were not eligible to return to work for 14 days from their positive result, while symptomatic employees were required to wait 14 days plus 3 days since the resolution of fever. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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The New York nursing home has received citations for medication errors and pressure ulcer care.

Salamanca Rehabilitation & Nursing Center has received received 68 citations for violations of public health code between 2017 and 2021, according to health records accessed on March 19, 2021. The Salamanca nursing home’s citations resulted from a total of four surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not ensure that residents were protected from the use of unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” An August 2019 citation found that Salamanca Rehabilitation & Nursing Center failed to ensure such. The citation states specifically that one resident was kept on an antibiotic regimen “without adequate indications for its use.” In an interview, the facility’s Assistant Director for Nursing said that the underlying symptoms, “a single episode of burning upon urination” and an increase in temperature, did not meet the nursing home’s “criteria for antibiotic use.” A plan of correction undertaken by the facility included a review of its antibiotics policies and procedures.

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An investigation found that nursing homes with five-star ratings often received citations for abuse and neglect.

A new investigation by the New York Times examines how nursing homes use the star rating system to “mislead the public.” As the article explains, the nursing home star rating system, in which one star is the lowest rating and five star is the highest ratings, has been “a popular way for consumers to educate themselves and for nursing homes to attract new customers.”

However, the report suggests, the system in fact offers “a distorted picture of the quality of care” at nursing homes, with many facilities manipulating the rating system to conceal failings that led to disproportionate nursing home resident deaths during the Covid-19 pandemic. The Times ultimately found that residents “at five-star facilities were roughly as likely to die of the disease as those at one-star homes.” Continue reading

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The Delmar, New York nursing home has also received $20,000 in fines.

Delmar Center for Rehabilitation and Nursing has received 80 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on March 5, 2021, as well as two fines totaling $20,000 since 2013. The Delmar nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code stipulates that nursing homes must ensure that “medication error rates are not 5 percent or greater.” A September 2020 citation found that Delmar Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that a medication error rate of 33.33% was observed during a medication pass, with four residents affected. Among other things, it describes a resident whose diabetes medication was administered more than ninety minutes after they were scheduled; a resident who refused their full dose but whose physician was not notified of such; and a resident whose medications were administered more than two-and-a-half-hours after they were scheduled. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

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The Pearl Nursing Center of Rochester has received citations for accident hazards and medication errors.

The Pearl Nursing Center of Rochester has received 121 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on February 28, 2020, as well as four fines totaling $20,000 since 2011. The Rochester nursing home’s citations resulted from a total of 11 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to avoid accidents. Section 483.25 of the Federal Code guarantees nursing home residents the right to adequate supervision to prevent accidents. A December 2019 citation found that The Pearl Nursing Center of Rochester failed to ensure such. The citation states specifically that one resident who had been identified upon admission as an elopement risk was not given a wanderguard supervision device until after they eloped from the facility. The citation goes on to describe another resident whose aspiration precautions were not properly followed in an instance where their meal was not cut up “and the resident attempted to put the whole rolled pasta in their mouth.” The citation states that these deficiencies had the “potential to cause more than minimal harm.”

Bridgewater Center for Rehabilitation & Nursing suffered 26 confirmed and 15 presumed COVID-19 deaths as of February 4, 2021, according to state records. The facility has also received 41 citations for violations of public health code between 2017 and 2020, according to New York State Department of Health records accessed on February 12, 2020. The Binghamton nursing home’s citations resulted from a total of six surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not implement proper measures to prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes are required to keep residents “free of any significant medication errors.” A June 2017 citation found that Bridgewater Center for Rehabilitation & Nursing failed to ensure such for three residents. In one case, the citation states, a resident’s orders for an antipsychotic medication “were not clarified when a change in dosage was made.” In two other cases, residents who had orders for fingerstick and sliding scale insulin administration during mealtimes were not administered such according to meal times. A plan of correction undertaken by the facility included the in-servicing of nursing staff on medication policies and procedures.

2. The nursing home did not provide adequate treatment and services to prevent and heal pressure ulcers. Section 483.25 stipulates that nursing homes must provide residents with receive care and services to prevent the development of pressure ulcers, and to provide residents with pressure ulcers necessary treatment and services to promote healing and prevent infection. A June 2017 citation found that Bridgewater Center for Rehabilitation & Nursing failed to ensure such. The citation states specifically that a resident who was documented at risk for pressure ulcer development, and who used a pressure-reducing device in their chair and bed, had no documented evidence that they were provided with off-loading boots per their care instructions, and ultimately developed a pressure ulcer on their left heel. In a pair of interviews, a nurse at the facility stated that the resident had refused to wear the boots. A plan of correction undertaken by the facility include the in-servicing of nursing staff on the facility’s pressure ulcer policies and procedures.

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The New York nursing home was cited for failing to ensure patients are not administered unnecessary psychotropic medication.

Elderwood at Williamsville suffered three confirmed COVID-19 deaths as of January 23, 2021, according to state records. The facility has also received 19 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 23, 2020. The Williamsville nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to ensure each resident environment is ‘as free of accident hazards as is possible.” A February 2019 citation found that Elderwood at Williamsville failed to ensure such. The citation states specifically that three resident units “had issues involving electric heating units in resident rooms with metal surfaces that were very hot to touch and were not shielded from resident access.” In an interview, the facility’s Director of Maintenance said that the nursing home “does not monitor the metal surface temperatures of wall-mounted electric heaters.” A plan of correction undertaken by the facility included the movement of resident beds away from the heaters.

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A nursing home in Cheektowaga, New York has received 27 health citations in the last four years.

Elderwood at Cheektowaga suffered 18 confirmed COVID-19 deaths as of January 23, 2021, according to state records. The facility has also received 27 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 23, 2020. The Cheektowaga nursing home’s citations resulted from a total of six surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent and control infection. Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain an infection control program “designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” A November 2019 citation found that Elderwood at Cheektowaga failed to ensure such. The citation states specifically that in one resident unit, dirty bed linens “were placed directly on the floor without a protective barrier,” and that in another unit, oxygen tubing “was observed directly on the floor during multiple observations,” all in contravention of facility policy. A plan of correction undertaken by the facility included the discarding of the tubing and the re-education of the staff member who placed dirty linens on the floor.

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