Articles Posted in Medication Errors

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The Hamlet Rehabilitation and Healthcare Center at Nesconset received 20 citations for being in violation of public health code between 2018 and 2022 after a total of 3 inspections by state surveyors found multiple deficiencies within the facility.

The Hamlet Rehabilitation and Healthcare Center at Nesconset received 20 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 13, 2022. The Nesconset nursing home’s citations resulted from a total of three inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately keep residents free from the use of unnecessary psychotropic drugs. Under Section 483.45 of the Federal Code, nursing homes must maintain resident drug regimens free from the unnecessary use of medications that have an effect on “brain activities associated with mental processes and behavior.” A 2019 citation found that The Hamlet Rehabilitation and Healthcare Center at Nesconset failed to ensure such. The citation specifically describes a resident who was administer such a medication without documented evidence of an appropriate diagnosis or the development of a comprehensive care plan to address such a diagnosis. In an interview, the facility’s attending physician said he was unaware if the resident had a history that would merit the medication. A plan of correction undertaken by the facility included a review of the resident’s medication and discontinuation of the medication.

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According to New York State Department of Health records, Quantum Rehabilitation and Nursing has received 30 citations for being in violation of public health code between 2018 and 2022.

Quantum Rehabilitation and Nursing received 30 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 6, 2022. The Middle Island 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 the administration of unnecessary drugs. Section 483.45 of the Federal Code requires nursing homes to keep their residents’ drug regimens “free from unnecessary drugs.” An April 2021 citation found that Quantum Rehabilitation and Nursing failed to ensure such. The citation specifically describes an instance in which a resident received antipsychotic medications in the absence of behavioral indications for such a medication. In an interview, the facility’s Director of Nursing Services stated that “non-pharmacological interventions should be attempted prior to the start of an Antipsychotic medication,” and further that “behaviors that warranted the start of the medication should be documented.” A plan of correction undertaken by the facility included the in-servicing of licensed nurses. 

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Medford Multicare Center for Living received 26 citations for being in violation of public health code between 2018 and 2022 after a total of 9 surveys were performed by state inspectors.

Medford Multicare Center for Living received 26 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 6, 2022. The Medford nursing home’s citations resulted from a total of 9 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes must keep their residents “free of any significant medication errors.” A July 2019 citation found that Medford Multicare Center failed to ensure such. The citation specifically describes an instance in which a resident did not receive their physician-ordered medications upon admission, including insulin, an anticoagulant, and an antihypertensive. In an interview, the facility’s MD stated that in cases where medications are unavailable, he expects facility staff to call him so he can order a substitute, adding that the “insulin and antihypertensive medications were significant medications.” A plan of correction undertaken by the facility included the educational counseling of relevant staff.

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Hilaire Rehab & Nursing received 60 citations for being in violation of public health code between 2018 and 2022 after a total of 4 inspections by state surveyors.

Hilaire Rehab & Nursing received 60 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 6, 2022. The Huntington 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 undertake adequate infection control measures. Under Section 483.80 of the Federal Code, nursing homes must endeavor to prevent the development and transmission of communicable diseases by creating and maintaining an infection prevention and control program. A February 2022 citation found that Hilaire Rehab & Nursing failed to ensure such. The citation specifically describes an instance in which a licensed practical nurse placed a blood pressure cuff on three residents’ bare arms “without sanitizing the blood pressure cuff between the residents.” In an interview, the LPN “acknowledged [t]hat they… did not sanitize the blood pressure cuff between use” and further that “they should have sanitized the blood pressure cuff after each use.” A plan of correction undertaken by the facility included the education of nurses on proper infection control procedures.

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A recent report by the Long Term Care Community Coalition shares that deficiencies in nursing homes across the United States are not being classified as harmful to the residents, which appears to be false and potentially dangerous for many nursing home residents.

A recent report by the Long Term Care Community Coalition raises important questions about “no harm” deficiencies in nursing homes across the United States.  “No Harm” deficiencies are health violations cited by official surveyors that are classified as causing no harm to residents. As the LTCCC argues in its Elder Justice newsletter, “no harm” citations often appear on their face to indeed be harmful, and that because they rarely result in financial penalties, this potentially erroneous classification leaves nursing homes without any incentive to correct systemic deficiencies. The LTCCC report describes several recent “no harm citations,” asking the reader whether the classification appears honest and accurate.  Continue reading

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Fulton Commons Care Center has received 12 citations for being in violation of public health code since 2018 after a total of 6 surveys by state inspectors lead to the discovery of multiple deficiencies within the East Meadows nursing home.

Fulton Commons Care Center received 12 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 15, 2022. The East Meadows 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 protect residents from abuse. Section 483.12 of the Federal Code provides nursing home residents the right to freedom from abuse. A January 2022 citation found that Fulton Commons Care Center failed to ensure such. The citation specifically states that after one resident reported that a licensed practical nurse “inappropriately touched” them, the LPN continued working at the facility. Less than two weeks after the resident reported that alleged incident, another resident reported that the same LPN “exposed their genitals” to them. Both residents, according to the citation, had “intact cognition,” and both “reported being afraid and not feeling safe.” The citation states that the nursing home “failed to notify law enforcements and the New York State Department of Health within 2 hours.” A plan of correction undertaken by the facility included the suspension and subsequent termination of the LPN, as well as the termination of the nursing supervisor “who failed to timely report” the first alleged incident.

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Central Island Healthcare has received 29 citations for being in violation of public health code since 2018 after a total of four surveys by state inspectors found deficiencies within the facility.

Central Island Healthcare received 29 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 15, 2022. The Plainview nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from the unnecessary use of psychotropic medications. Section 483.45 of the Federal Code stipulates that nursing homes who have not used psychotropic medications should not be given them unless medically necessary. An August 2019 citation found that Central Island Healthcare failed to ensure such. The citation specifically describes a resident who was started on an unspecified antipsychotic medication “without any documented evidence of the clinical need for the medication.” The citation goes on to state that the medication’s administration frequency was increased from once a day to twice at day at the request of the resident’s family, and that the dosage was doubled “due to a medication error entry.” A plan of correction undertaken by the facility included the resident’s examination by a physician and a psychiatrist, after which the resident’s medication dosage was adjusted.

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Sapphire Nursing and Rehab at Goshen has received 19 citations for being in violation of public health code since 2018 after multiple deficiencies were found during a total of 4 surveys by state inspectors.

Sapphire Nursing and Rehab at Goshen received 19 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Goshen nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from the unnecessary use of psychotropic medications. Under Section 483.25 of the Federal Code, nursing homes must ensure resident drug regimens are free of unnecessary drugs, including psychotropic drugs. A December 2019 citation found that Sapphire Nursing and Rehab at Goshen failed to ensure such. The citation states specifically that there was a lack of documentation indicating the continued use of an antipsychotic drug by one resident. In an interview, the facility’s Registered Nurse Manager stated that the resident “did not have behavior issues” and that “non-pharmacalogical interventions had not been implemented prior to the start” of the anti-psychotic drug regimen. A plan of correction undertaken by the facility included the review of the resident’s medical record and the implementation of a gradual dose reduction.

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Glen Arden received 15 citations for being in violation of public health code between 2018 and 2022 after a total of 3 surveys by state inspectors found multiple deficiencies within the nursing home.

Glen Arden received 15 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Goshen 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 provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes must provide residents with a level of care necessary to promote the healing of pressure ulcers. A September 2020 citation found that Glen Arden failed to ensure such. The citation specifically states that a nurse practitioner’s recommendations to promote the healing of a “new deep tissue injury” and scab on a resident’s toe “were not implemented timely.” In an interview, the nurse practitioner said that this lapse could potentially result in an infection. A plan of correction undertaken by the facility included the updating of the resident’s care plan and treatment of the resident’s wound. 

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The Willlows at Ramapo Rehabilitation and Nursing Center has received 23 citations for being in violation of public health code since 2018 after a total of 4 surveys by state inspectors found multiple deficiencies within the facility.

The Willows at Ramapo Rehabilitation and Nursing Center received 23 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Haverstraw nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate supervision to prevent elopement. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with a level of supervision necessary to prevent accidents. A September 2021 citation found that The Willows at Ramapo failed to ensure such. The citation specifically describes an incident in which the facility’s receptionist “left the front desk without coverage, leaving the front desk unattended,” after which a resident with severe cognitive impairment “was able to exit the facility undetected by staff.” The resident was later discovered in the parking lot by facility staff. A plan of correction undertaken by the facility included an audit of residents at risk of elopement to ensure the proper placement and functioning of their wander guard devices.

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