Articles Posted in Medication Errors

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Fort Tryon Center for Rehabilitation has received 20 citations since 2017 for failing to prevent medication errors, failing to protect its residents from being verbally abused by staff members, and for not taking the proper precautions needed to prevent infections.

Fort Tryon Center for Rehabilitation and Nursing received 20 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 14, 2022. The Manhattan nursing home’s citations resulted from a total of eight inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent medication errors. Under Section 483.25 of the Federal Code, nursing homes must keep residents “free of any significant medication errors.” A June 2021 citation found that Fort Tryon Center failed to ensure such. The citation states specifically that three residents “were ordered to take nothing by mouth” despite a physician’s orders for medications to be administered to them by mouth. A plan of correction undertaken by the facility included the review, clarification, and revision of MD orders for the residents in question, as well as the education of licensed nurses on matters including the verification of physician orders. 

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Campbell Hall Rehabilitation Center has received a total of 77 citations since 2017 for being of violation of public health code and for failing to properly care for their residents.

Campbell Hall Rehabilitation Center received 77 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 7, 2022. The facility was recently placed on the Centers for Medicare and Medicaid Services’ list of “Special Focus Facilities” candidates, meaning it has a record of serious citations. The Campbell Hall nursing home’s citations resulted from a total of 15 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with necessary care and treatment to promote the healing of pressure ulcers. An August 2021 citation found that Campbell Hall Rehabilitation Center failed to ensure such for one resident. The citation states specifically that the resident’s records contained “no consistent documentation… to prove that that interventions and treatments were administered in accordance with the written care plan, and physician’s orders.” In interviews, facility nurses said that they conducted wound treatment but neglected to record it, with one saying that they “sometimes overlook signing treatments” in the resident’s records. A Certified Nursing Assistant said in one interview that she had observed the resident’s wound deteriorating and accordingly reported this to a nurse. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Warren Center for Rehabilitation and Nursing has received over 70 citations for being in violation of public health code since 2017 and has been fined a total of $14,000 since 2011.

Warren Center for Rehabilitation and Nursing has received 73 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 7, 2022. The facility has additionally received three fines totaling $14,000 since 2011, the most recent being a $10,000 fine issued in December 2017. The Queensbury nursing home’s citations resulted from a total of eight surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent the use of unnecessary medications. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” A September 2021 citation found that Warren Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that one resident received an opioid pain medication even though their medical record did not include a clinical indication supporting its use, nor documentation to support an increase in dosage. In an interview, one of the facility’s Certified Nursing Assistants said that “they did not provide non-pharmacological interventions for pain management for this resident and the resident was not care planned for specific interventions for the nurse assistants to provide.” A plan of correction undertaken by the  facility included the re-education of licensed nurses on policy regarding medication administration.

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Since 2017, Buffalo Center for Rehabilitation and Nursing has received over 100 citations and a total of four fines for being in violation of public health code and failing to protect its residents.

Buffalo Center for Rehabilitation and Nursing has received 118 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on December 31, 2021. The facility has additionally received four fines totaling $38,000 since 2008, the most recent being a $10,000 fine issued in July 2021. The Buffalo nursing home’s citations resulted from a total of 14 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home failed to adequately protect residents from abuse and neglect. Section 483.12 of the Federal Code ensures nursing home residents the right “to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A July 2021 citation found that Buffalo Center for Rehabilitation and Nursing failed to ensure such. The citation specifically describes an incident in which a Certified Nursing Assistant entered a resident’s bathroom while the resident was in it, after which the resident “became agitated, an altercation ensued, and [the CNA] slammed the door causing the resident to fall to floor.” The resident was subsequently sent to the hospital and returned with conditions redacted by the citation. In a separate instance described by the citation, another resident was discovered on their floor of their room with bruising on their left eye and forehead. Although the resident had been assessed as at risk for falls, the citation states, there was no floor mat beside their bed as provided for by their care plan. The citation states that these deficiencies caused “actual harm.”

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Throgs Neck Rehabilitation and Nursing Center in the Bronx has received 22 citations in the last four years after surveys by state inspectors and has been fined $2,000 for violating health codes.

Throgs Neck Rehabilitation & Nursing Center has received 22 citations for violations of public health code between 2017 and 2021, according to records accessed on December 17, 2021. It also received a $2,000 fine in 2021 over findings it violated health code provisions. The Bronx nursing home facility’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 prevent medication errors. Section 483.45 of the Federal Code stipulates that medication error rates at nursing homes must not be “5 percent or greater.” A September 10, 2021 citation found that Throgs Neck Rehabilitation & Nursing Center failed to ensure such. The citation states specifically that one resident “was not administered with six (6) of the prescribed medications due” during an observation. The citation states further that the Licensed Practical Nurse administering the resident’s medications did “not inform the resident that some medications were not being administered at that time.” In an interview, the LPN told a state health inspector that “the missed medications were not available in the medication cart and they should have informed the resident.” The LN added that they planned to search for the medications or contact the facility’s pharmacy to confirm when the medications were re-ordered, or to re-order them if necessary. In an interview, the facility’s Director of Nursing stated “that the nurses are supposed to follow up and get medication before they are exhausted, and they did not know why the staff are not doing that.” A plan of correction undertaken by the facility included the ed-education and in-servicing of relevant staff. 

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Ontario Center for Rehabilitation and Healthcare has been issued a fine and has received a total of 77 citations since 2017 for failing to keep the residents safe from falls and accidents, for failing to treat and prevent pressure ulcers, and for failing to administer medication in a timely manner.

Ontario Center for Rehabilitation and Healthcare has received 77 citations for violations of public health code between 2017 and 2021, according to records accessed on December 4, 2021. It was also issued a $12,000 fine in 2016 over findings it violated health code provisions regarding medication errors and resident rights. The Canandaigua nursing home facility’s citations resulted from a total of 12 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 stipulates that nursing homes must provide residents with adequate supervision and assistance devices to prevent accidents. A June 2021 citation found that Ontario Center for Rehabilitation and Healthcare failed to ensure such. The citation specifically describes a resident on aspiration precautions who was not provided with supervision at mealtimes, and another resident who “did not receive assistance with ambulation and transfers to minimize risk of falls.” The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the counseling of the residents’ care staff. 

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Recent data shows that more than 250,000 nursing home residents across the country have been given unnecessary antipsychotic drugs by staff in order to sedate the patients.

A recent analysis of federal nursing home citation data by the Long-Term Community Care Coalition found that nearly 20% of nursing home residents in the United States have been administered one or more antipsychotic medications, the unnecessary use of which are prohibited by federal law. That figure constitutes more than 250,000 nursing home residents.  Continue reading

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A recent report shares that federal data from nursing homes across the country has agencies mostly concerned about the use of antipsychotic drugs, failure to control infection, failure to prevent and properly care for pressure ulcers, and issues with insufficient staffing.

The Long-Term Community Care Coalition recently released a report analyzing federal data concerning the oversight of nursing home facilities across the country. The report draws high-level conclusions about nursing home surveys and enforcement actions taken by state, regional, and federal regulatory authorities. Specific enforcement areas concerned include antipsychotic drug use, infection control, pressure ulcer care, staffing issues, and resident rights. Continue reading

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Van Duyn Center for Rehabilitation and Nursing in Syracuse has received a total of 89 citations and was placed on a list by the federal government after inspectors found serious issues that could name this nursing home one of the worst facilities in the country.

A “troubled” nursing home in Syracuse, New York has been placed on the federal government’s “special focus facilities list,” meaning it may end up named one of the worst-performing facilities in the country for a second time, according to a report by Syracuse.com. Continue reading

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During the Covid-19 pandemic nursing homes had as many as 40,000 deaths due to staff being overworked and neglecting many nursing home residents.

An Associated Press analysis of 15,000 nursing homes across the United States found that the Covid-19 pandemic may have resulted in as many as 40,000 excess deaths—that is, premature deaths from causes other than Covid-19. Experts suggested to the AP that nursing home residents may have died of neglect as overworked staffers tended to residents suffering from the disease. Continue reading

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