Articles Posted in Medication Errors

Bezalel Rehabilitation and Nursing Center received 25 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 9, 2020. The Far Rockaway 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 ensure residents’ drug regimens were free from unnecessary psychotropic medications. Section 483.45 of the Federal Code requires that nursing homes keep residents’ drug regimens free from the unnecessary use of any drugs that affect “brain activities associated with mental processes and behavior. A June 2019 citation found that Bezalel Rehabilitation and Nursing Center did not ensure a resident properly received gradual dose reductions to discontinue the use of a psychotropic medication. The citation states specifically that the resident was admitted to the nursing home already receiving the medication, but the facility did not attempt a gradual dose reduction, and “there was no evidence that the resident displayed any mood or behavioral symptoms that warranted continued use of the medication without a GDR attempt.” The citation states further that the nursing home did not attempt, before the resident was admitted, to confirm their psychiatric history.

2. The nursing home did not maintain an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with an environment as free as possible from accident hazards, and with adequate supervision to ensure that residents do not experience accidents. A June 2016 citation found that the nursing home did not take adequate accident prevention measures with respect to one resident who had planned monitoring for swallowing difficulty and aspiration precautions. According to these citations, the precautions included “being observed while eating, sitting upright while eating and for at least 30 minutes after eating, never eat in bed and if resident experiences coughing or secretions, during or without meal hold the feed till totally clear.”

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Highland Care 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 January 10, 2020. The Jamaica 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 (bedsore) pressure ulcer care. Section 483.25 of the Federal Code requires nursing homes to ensure that residents receive “care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable.” A May 2019 citation found that Highland Care Center did not ensure a resident with a pressure ulcer received adequate care. An inspector specifically found that the resident’s pressure-relieving device for their foot/leg ulcer was “missing” and “not in place.” A Certified Nursing Aide stated in an interview that the resident’s heel booties had been sent to the laundry and should have been returned the following day, but when she checked the laundry they weren’t there; “she did not report this to her nurse,” the citation states. A plan of correction undertaken by the facility included nursing staff in-service education and the provision of new heel booties to the resident.

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Chapin Home for the Aging received 17 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Jamaica nursing home’s citations resulted from a total of four inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not protect residents from abuse and neglect. Under Section 483.12 of the Federal Code, nursing homes must ensure their residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A June 2019 citation found that Chapin Home for the Aging failed to comply with this section in an instance in which one resident was “observed in his room with his wheelchair leg rest in his hand, raised above” another resident, who was observed in bed “with multiple lacerations and… covered with blood.” The latter resident had lacerations on his scalp and his ear, as well as “excoriations” on his left shoulder and left upper arm. The resident was transferred to the local hospital, where he received 20 medical staples. The citation found that this deficiency on the nursing home’s part resulted in “actual harm.”

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Forest Hills Care Center received 18 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The facility was also the subject of a 2018 fine of $12,000 in connection to unspecified findings in a December 2017 survey. The Forest Hills nursing home’s citations resulted from a total of three inspections by state authorities. The violations they describe include the following:

1. The nursing home did not take adequate measures to protect residents from neglect. Section 483.12 of the Federal Code requires nursing homes to protect residents from “abuse, neglect, misappropriation of resident property, and exploitation.” A December 2017 citation found that Forest Hills Care Center did not ensure a resident’s right to freedom from neglect. The citation specifically found that a Certified Nursing Assistant “willfully neglected to implement” a resident’s Comprehensive Care Plan requirement for the resident to be transferred from their bed to their wheel chair by two persons and the use of a Hoyer Lift. As a result of this failure, the resident fell while being transferred and sustained an injury to their hip.

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Forest View Center for Rehabilitation and Nursing Cited received 20 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Forest Hills nursing home’s citations resulted from a total of three inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not keep residents free from significant medication errors. Under Section 483.45 of the Federal Code, nursing home residents have a right to be “free of any significant medication errors” in their drug regimens. An August 2016 citation found that the nursing home failed to comply with this section in an instance in which a resident was administered an unidentified antipsychotic medication after it was ordered to be discontinued and replaced with another medication; instead, the resident was administered both. In an interview, the facility’s Medical Director stated that the resident “should not have been receiving two antipsychotic medications daily.”

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Silvercrest received 19 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 13, 2019. The Jamaica nursing home’s citations resulted from a total of four inspections by state authorities. The violations they describe include the following:

1. The nursing home did not take adequate measures to prevent residents from sustaining falls. Section 483.25 of the Federal Code requires nursing homes to ensure that residents receive supervision to prevent them from sustaining accidents. According to a September 2018 citation, Silvercrest did not adequately supervise one resident, resulting in the resident falling. An inspector specifically found that the resident, who had been “assessed as a high risk for falls,” was left unattended in one of the facility’s hallways, and sustained a fall. When the resident was found by staff, she was observed suffering from “pain and swelling of the left shoulder” and transferred to a local hospital for examination.

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Park Gardens Rehabilitation & Nursing 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 21, 2019. Those citations number six more than the statewide average of 32. The Bronx nursing home’s citations resulted from a total of three inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure its residents’ drug regimens were free from unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs,” going on to clarify that “unnecessary” refers to any drug used in excessive dosage, for excessive duration, without adequate monitoring or indications, and/or in the presence of adverse consequences. A March 2017 citation found that Park Gardens Rehabilitation and Nursing Center failed to comply with this section in two separate capacities. In one, the facility did not provide “adequate monitoring” of a diabetic resident who had recently received an increase in their insulin dosage, so as to figure out whether the increase was effective or yielded any ill effects. Separately, the citation notes, the nursing home increased another resident’s dosage of an unidentified medication “without documentation for the reason of the increase.” The citation states that these failures resulted in the “potential to cause more than minimal harm” to residents.

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King Street Home received 32 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 Port Chester nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did take adequate steps to protect residents from abuse. Under Section 483.12 of the Federal Code nursing homes must ensure residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A July 2019 citation found that King Street Home did not ensure residents’ right to be free from abuse in an instance where a Certified Nursing Assistant was accused of being “rough” with a resident. After the resident reported the allegation, the assistant was removed from contact with that resident, but was not promptly removed from contact with other residents while the allegation was investigated. In an interview, the facility’s administrator told an inspector that the assistant “should have been removed from all resident contact” in addition to the resident in question.

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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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