Articles Posted in Medication Errors

East Neck Nursing & Rehabilitation Center received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 28, 2020. The West Babylon 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 prevent residents from being administered unnecessary drugs. Section 483.25 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs.” A May 2016 citation found that East Neck Nursing & Rehabilitation Center did not ensure such for one resident. The citation states specifically that there was an increase in the resident’s antidepressant medication without any “documented evidence as to why the medication was increased.” In an interview, the facility’s neurologist was asked where the documentation for the dosage increase was, he said that he “will write it next time.” A plan of correction undertaken by the facility included an updating of the resident’s medical record and re-education of nursing staff regarding unnecessary medications.

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Gurwin Jewish Nursing and Rehabilitation Center received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 29, 2020. The Commack nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent verbal abuse. Section 483.12 of the Federal Code requires nursing homes to ensure each resident’s “right to be free from abuse.” A July 2018 citation found that Gurwin Jewish Nursing and Rehabilitation Center did not ensure such for one resident. The citation states specifically that a Certified Nursing Assistant “told the resident that she smelled and instructed the resident to void in the brief when the resident requested toileting assistance” from the CNA, while another CNA was present. The citation states that the second CNA neglected to report the abuse to appropriate authorities. A plan of correction undertaken by the facility included the suspension of the first CNA, and noted that the second CNA “is no longer employed.”

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Berkshire Nursing & Rehabilitation Center received 26 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 27, 2020. The West Babylon 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 implement adequate measures to protect its residents from sexual abuse. Under Section 483.12 of the Federal Code, nursing homes have a right “to be free from abuse.” A September 2019 citation found that Berkshire Nursing & Rehabilitation Center did not ensure one resident was free from sexual abuse. The citation states specifically that a “cognitively intact resident… inappropriately touched” a resident with “severely impaired cognition,” and that the nursing home did not launch an investigation “until 2 days after the incident.”  A plan of correction undertaken by the facility included the suspension and re-education of the Nursing Supervisor found to be responsible “for failure to communicate.”

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Good Samaritan Nursing and Rehabilitation Care Center received 21 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 28, 2020. The Sayville 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 (bedsore) care. Section 483.25 of the Federal Code requires nursing homes to ensure that a resident with pressure ulcers receives “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A March 2018 citation found that Good Samaritan Nursing and Rehabilitation Care Center did not ensure such for one resident. The citation states specificaly that the resident developed a deep tissue injury on their right heel while in the facility, but that “multiple observations were made of the heel not being offloaded (to prevent contact with any surface) per physician’s orders.” In an interview, the facility’s Director of Nursing Services stated that the facility should have provided the resident with “better coordinated” care and that the resident’s “care plan should have been updated” with more specific interventions.

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Bellhaven Center for Rehabilitation and Nursing Care received 23 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 27, 2020. The Brookhaven 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 pressure ulcer (bedsore) care. Section 483.25 of the Federal Code requires nursing homes to ensure that residents who enter without pressure sores do not develop them “unless the individual’s clinical condition demonstrates that they were unavoidable.” A July 2016 citation found that Bellhaven Center for Rehabilitation and Nursing Care did not ensure effective care for a resident at risk of developing a pressure ulcer so as to prevent them from developing a pressure ulcer. The citation states specifically that the resident’s medical records “lacked an individualized plan of care specific to the resident,” and that the resident developed a Nosocomial Stage III pressure ulcer. According to the citation, records revealed that there was “no documented evidence that the resident was turned and position” to prevent the development of ulcers, and a facility staffer stated that “there is no documented evidence that ski n checks were completed.” The citation states that this deficiency resulted in the “potential to cause more than minimal harm.”

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Townhouse Center for Rehabilitation & Nursing received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 20, 2020. The facility has also received four fines: a 2019 fine of $10,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions; a 2018 fine of $16,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions; a 2017 fine of $2,000 in connection to findings in a 2017 inspection that it violated health code provisions regarding the use of physical restraints; and a 2017 fine of $4,000 in connection to findings in a 2016 inspection that it violated health code provisions regarding quality of care and administrative practices. The Uniondale nursing home’s citations resulted from a total of ten surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not ensure residents were protected from neglect. Section 483.12 of the Federal Code guarantees nursing home residents the right to “be free from… neglect.” An August 2018 citation found that Townhouse Center for Rehabilitation & Nursing did not ensure such for one resident. The citation describes specifically an instance in which the facility’s security guard on duty “left his post unattended,” after which a resident eloped. The resident was later found a block away from the nursing home and returned to it ‘without any injury.” A plan of correction undertaken by the facility included the termination of the security guard in question.

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The Grand Pavilion for Rehab & Nursing at South Point received 32 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 20, 2020. The facility has also received two fines: one 2016 fine of $8,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding resident rights and administration; and one 2011 fine of $10,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding pressure sores. The Island Park nursing home’s citations resulted from a total of seven surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately protect residents from nursing home abuse. Under Section 483.12 of the Federal Code, nursing homes have a right to “be free from abuse, neglect, misappropriation of resident property, and exploitation.” A March 2019 citation found that The Grand Pavilion for Rehab & Nursing at South Point did not ensure one resident’s right to freedom from sexual abuse. The citation states specifically that a “cognitively intact resident… inappropriately touched another resident… who was assessed as having impaired cognition.” A plan of correction undertaken by the facility included the placement of the first resident on one-to-one observation until he could be “discharged to another appropriate facility.”

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Acadia Center for Nursing and Rehabilitation received 16 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 21, 2020. The facility also received a 2015 fine of $4,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding resident medication errors. The Riverhead, NY 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 ensure residents were protected from abuse. Section 483.12 of the Federal Code stipulates that nursing home residents have “the right to be free from abuse.” An October 2019 citation found that Acadia Center for Nursing and Rehabilitation did not ensure one resident was free from abuse. The citation states specifically that a Certified Nursing Assistant witnessed a Licensed Practical Nurse “using foul language and hitting a legally blind resident with cognitive impairment twice on his forehead.” The citation states further that video surveillance documented this incident, and that the LPN was “immediately removed from her assignment.” A plan of correction undertaken by the facility included the termination of the LPN. Continue reading

Apex Rehabilitation & Care Center received 29 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 21, 2020. The Huntington Station 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 protect residents from abuse. Section 483.12 of the Federal Code requires nursing homes to ensure residents’ right to freedom from abuse. A December 2019 citation found that Apex Rehabilitation & Care Center did not ensure such for two residents. The citation states specifically that two Certified Nursing Assistants “placed the back of [a resident’s] bra strap over the wheelchair handle when the resident was exhibiting behavioral symptoms and constantly trying to stand up from the wheelchair.” The citation states further that one of those CNAs was captured on the facility’s video surveillance pushing a resident “to sit back in his wheelchair.” A plan of correction undertaken by the facility included the interview, suspension, investigation, and termination of both CNAs.

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Williamsbridge Center for Rehabilitation and Nursing received 29 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. These citations include one that authorities determined to reflect “a severe, systemic deficiency.” The Bronx 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 provide an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide an environment as free as possible from accident hazards, and to provide proper supervision to prevent accidents. A citation issued on April 23, 2019 found that the nursing home failed to adequately supervise a resident with a history of attempted elopement, who eloped from the facility on April 5, 2019. According to the citation, the resident was not accounted for during an 11 AM head count, and the nursing home did not launch a search for the resident until 2:30 PM. As of the date of the citation, the resident’s whereabouts remained unknown. The Department of Health found that this failure resulted in “immediate jeopardy to resident health or safety” and reflected a systemic deficiency.

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