Articles Posted in Medication Errors

New York State Veterans Home at Montrose: Infection Citation, Covid Deaths

New York State Veterans Home at Montrose suffered 13 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 26 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. One of those citations detailed findings of deficient infection control practices. The Montrose nursing home’s citations resulted from a total of five surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not employ adequate measures to prevent and control infection. Under Section 483.80 of the Federal Code, nursing home facilities are required to establish and maintain a program to prevent and control infection, one that is adequately designed to ensure residents a safe and sanitary environment. An August 2016 survey found that New York State Veterans Home at Montrose did not ensure the effective establishment and/or maintenance of an infection prevention and control program. The survey lacks additional detail on the citation, though it specifies that the scope of the deficiency was “widespread” and “pervasive throughout the facility”; that it had caused no actual harm and put no residents in immediate jeopardy, although it “has caused minor discomfort and has the potential to cause more than minimal harm”; and that it was corrected by the facility as of November 5, 2016.

Long Island State Veterans Home suffered 66 fatalities from Covid-19 as of July 18, 2020, per state records. The nursing home also received 10 citations finding it violated public health code between 2016 and 2020, according to health records accessed on July 20, 2020. The Stonybrook nursing home’s citations resulted from a total of two surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not take adequate steps to prevent accidents. Section 483.25 of the Federal Code stipulates that nursing homes must ensure resident environments remain as free from accident hazards as is possible, and that residents receive adequate supervision to prevent accidents. An August 2016 citation found that Long Island State Veterans Home failed to ensure such for one resident. The citation specifically describes a resident who “was observed during a meal being fed by a family member using unsafe techniques.” It goes on to state that the resident was “seated with his head slightly extended,” while the family member was standing over the resident “Forcing his hands down on the table with her left hand while feeding the resident with a spoon.” In an interview, the facility’s Charge Nurse Registered Nurse told a surveyor that the family member “does feed the resident for lunch and dinner three times a week.” In a separate interview, the family member said “she holds his hands down as a distraction so he will eat the food off the spoon.” A plan of correction undertaken by the facility included the education of the family member regarding safe feeding practices.

2. The nursing home did not ensure the reporting of medication irregularities. Section 483.45 of the Federal Code provides for the regular review of resident drug regimens by a licensed pharmacist, and requires the pharmacist to report any irregularities to the resident’s attending physician. A March 2019 citation found that Long Island State Veterans Home did not ensure such. The citation states specifically that a resident received 2.5 milligrams of a redacted medication every eight hours when necessary for 14 days, “without supporting documentation for the use.” The citation additionally states that there was “no documented evidence the Pharmacy Consultant” reported the irregularity to the resident’s physician. The citation states that this deficiency had the “potential to cause more than minimal harm.”

A new edition of the Long Term Care Community Coalition Elder Justice Newsletter asks a simple question: does providing a nursing home resident breakfast in their soiled bed constitute harm? How about failing to provide a stop date for a resident’s psychotropic medication?

“No Harm” deficiencies refer to citations of rule violations at nursing homes in which health inspectors determined that the violations caused “no harm” to residents. As the LTCCC notes, data provided by the Centers for Medicare & Medicaid Service, which mandate minimum standards of care for nursing homes participating in their programs, show that more than 95% of nursing home health citations describe “no harm” deficiencies. The LTCCC argues, however, that these no harm citations reflect systemic failures to recognize the suffering of nursing home residents, which in turn results in systemic failures to hold nursing homes accountable through financial penalties. “In the absence of a financial penalty,” the newsletter states, “nursing homes may have little incentive to correct the underlying causes of resident abuse, neglect, and other forms of harm.”

The newsletter proceeds to provide instances of health violations in which regulators determined that no harm was done to the resident in question. For example:

Oklahoma’s new elder abuse law cracks down on the use by nursing homes of “chemical restraints” on their patients. According to America Nurse Today, chemical restraints are unnecessary medications used to “restrict a patient’s movement or behavior.” Importantly, these chemical restraints are not a part of a standard approved treatment. Most commonly, nursing homes use antipsychotic medications – powerful psychotropics with a variety of side effects, drug interactions, and risks.

While it is undoubtedly immoral and unethical to force someone without a proper diagnosis to take powerful mind-altering medications just to make them more compliant with nursing staff, the practice is sadly very common. According to Health Affairs, 14 percent of all nursing home patients are on an antipsychotic. The industry watchdog estimates that 83 percent of these prescriptions are for an unapproved or off-label use. A report by the Centers for Medicaid and Medicare Services found that 40 percent of nursing home residents on antipsychotics do not have a diagnosis of psychosis.

To counter the scourge of chemical restraints meant to make elderly residents docile, Oklahoma is cracking down on the nursing homes. Under Oklahoma’s new law, a doctor must conduct a medical exam, diagnose the patient, and obtain informed written consent from the nursing home resident or their caregiver before writing a prescription for antipsychotics. After passing the law, Oklahoma’s governor noted that the state with the most nursing home residents on antipsychotics (20 percent) will now have the toughest law against it.

Sapphire Nursing and Rehab at Goshen received 49 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on February 20, 2020. The Goshen 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 properly implement procedures to prevent residents from eloping. Section 483.25 of the Federal Code requires nursing home facilities to provide residents with “adequate supervision and assistance devices to prevent accidents,” including unsafe wandering off the facility’s premises. A June 2019 citation found that Sapphire Nursing and Rehab at Goshen did not ensure one resident was adequately supervised. The citation states that the resident had been assessed at low risk for elopement, but that the facility did not reassess the resident’s supervisory needs after the resident “behavior changes potentially related to increased risk for elopement.” The resident, according to the citation, “exited the building undetected, passing thorough a supervised common room and a supervised lobby, when the assigned staff were distracted by residents that required immediate attention in each of those areas.” The citation goes on to state that the resident was discovered by staff about 20 minutes afterward, then escorted back into the facility. This deficiency, according to the citation, had the “potential to cause more than minimal harm.”

2. The nursing home did not keep maintain sufficiently low medication error rates. Section 483.45 of the Federal Code stipulates that nursing home facilities must keep their medication error rates below five percent. A January 2018 citation found that Sapphire Nursing and Rehab at Goshen a rate below five percent for two residents. An inspector specifically observed administer one resident a multivitamin with minerals even though the physician’s orders “did not include instructions for the multiple minerals ingredient of the medication.” The inspector also observed a Licensed Practical Nurse incorrectly administer another resident’s eyedrops. The citation found that these deficiencies had the “potential to cause more than minimal harm.”

Bronx Center for Rehabilitation & Health Care received 44 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 12 more than the statewide average of 32. The Bronx nursing home’s citations resulted from a total of six inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure that residents’ drug regimens were free from unnecessary psychotropic medications. Under Section 483.45 of the Federal Code, nursing home facilities must keep residents’ drug regimens free from the unnecessary use of any drugs that affect “brain activities associated with mental processes and behavior,” including anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics. A January 2019 citation found that the nursing home failed to ensure that one resident was free from an unnecessary antipsychotic medication, in contravention of facility policy dictating that residents residents receive medications “at the lowest possible dosage for the shortest period of time,” and that they only receive such medications “when necessary to treat specific conditions for which they are indicated and effective.” As a result of the citation, the facility instituted a plan of correction in which the resident’s psychiatrist recommended a reduced dosage of the medication in question.

2. The nursing home did not ensure an environment free of accident hazards. Section 483.25 of the Federal Code stipulates that nursing home facilities are to provide an environment as free as possible from accident hazards, as well as adequate supervision to prevent residents from sustaining accidents. An October 2018 citation found that Bronx Center for Rehabilitation and Health Care did not provide adequate supervision to a resident who had been assessed as “high risk for elopement” and consequently placed on visual monitoring every 15 minutes. The citation states that the resident “successfully eloped the facility” through its gate and was later returned by local police officers. The nursing home’s investigation of the incident concluded that it was the result of “inadequate supervision” by the security guard, as well as a dietary aide’s “delayed reporting” of the resident’s elopement.

Andrus On Hudson received 22 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 $12,000, in January 2013, over alleged violations of sections of the health code relating to the administrative practices and the quality of care provided to residents. The Hastings-on-Hudson 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 ensure an environment free of accident hazards. Section 483.25 of the Federal Code stipulates that nursing home facilities must provide residents with an environment as free as possible from accident hazards, as well as adequate supervision and assistive devices to prevent residents from experiencing accidents. A September 2107 citation describes Andrus on Hudson’s failure to ensure that one of four residents reviewed was provided an adequately maintained assistive device to prevent him from leaving the facility without staff authorization or knowledge. An inspector found specifically that a resident at high risk of elopement, and with a history of attempted elopement, had been provided with an electronic device designed to alert staff when the resident “wanders into certain unsafe and unmonitored areas.” However, the citation states, the facility’s care planning team did not properly maintain the device according to its manufacturer’s guidelines, and as a result of a “tag pick up field [that] was weak,” the resident was able to exit the facility without staff being alerted. An investigation revealed that the device had been used beyond its battery’s expiration date, which the staff were unaware of.

2. The nursing home did not ensure its resident drug regimens were maintained free from unnecessary drugs. Section 483.45 of the Federal Code states that nursing home facilities must keep “each resident’s drug regimen… free from unnecessary drugs,” which includes drugs used in excessive duration and/or without adequate monitoring. A July 2019 citation states that Andrus on Hudson did not provide ongoing monitoring of a resident’s use of an antipsychotic medication to treat hiccups. Facility staff, as well as a review of clinical records, revealed that the resident was not being monitored for use of the medication, and that there was no nurses’ note addressing the resident’s hiccups. The citation states that this deficiency had “potential to cause more than minimal harm.”

Cypress Garden Center for Nursing and Rehabilitation 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 12, 2019. The Flushing nursing home’s citations resulted from a total of five inspections by state authorities. The violations they describe include the following:

1. The nursing home did not provide adequate supervision or assistive devices to prevent residents from falling. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments remain “as free of accident hazards as is possible” and to provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2016 citation found that Cypress Gardens did not ensure that a resident who had been identified as “High Risk” for falls received adequate supervision to prevent them. An inspector specifically found that in June 2016 the resident was observed on the floor after a fall, having “sustained abrasions to the forehead and left forearm.” According to the citation, the resident’s care plan interventions for falls included a chair alarm, but at the time he “did not have a bed or chair alarm in pace.” The citation found that this deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not implement proper measures to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to maintain and implement “an infection prevention and 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 September 2019 citation found that the nursing home failed to provide such in an instance when an eye doctor consulting at the facility “did not properly clean the overbed table used or perform hand hygiene prior to completing an eye exam.” An inspector observed the eye doctor wiping off an exam table with a paper towel and then placing his equipment bag on it while there were still “stains” on the table; the doctor then moved the table into a resident’s room, according to the citation, and performed an eye exam on the resident without performing hand hygiene beforehand, although he was observed performing hand hygiene afterward.

Waterview Nursing Care Center received 22 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 12, 2019. The facility was also the subject of a 2010 fine of $4,000 in connection to findings it failed to comply with health code provision concerning accidents and administrative practices. The Flushing 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 employ adequate measures to protect residents from abuse. Under Section 483.12 of the Federal Code, nursing home residents have the right to be free from abuse and neglect. A May 2019 citation found that Waterview Nursing Care Center failed to prevent residents from abuse in an instance in which one resident hit another resident with his wheelchair’s footrest. According to the citation, the resident who was hit “suffered a laceration and bleeding to his head,” and was subsequently transferred to a local hospital for care. The resident received four staples on his head before returning to the facility. A plan of correction undertaken by the facility included the transfer of the aggressor to another unit and his placement on regular visual checks.

2. The nursing home did not ensure its residents’ drug regimens were free from unnecessary medications. Under Section 483.45 of the Federal Code, nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs.” According to a November 2016 citation, Waterview Nursing Care Center did not ensure one resident’s drug regimen was free of unnecessary medications. An inspector specifically found that the resident was administered an antipsychotic medication even tough the facility did not have “documented evidence of non- pharmacological interventions being attempted prior to [the medications] administration.” In an interview, the facility’s psychiatrist said that the medication should not have been administered without documented evidence of such.

Promenade Rehabilitation and Health Care Center received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 2, 2020. The facility was also the subject of a 2016 fine of $8,000 in connection to findings it violated health code provisions regarding social services, accidents, quality assessment and assurance, and administrative practices and procedures. The Rockaway Park nursing home’s citations resulted from a total of six inspections by state surveyors. The violations they describe include the following:

1. The nursing home did ensure residents received adequate supervision to prevent elopement. Under Section 483.25 of the Federal Code, nursing home facilities are required to provide residents with a setting as free as possible from accident hazards, and with adequate supervision to prevent them from sustaining accidents such as elopement. A May 2018 citation found that Promenade Rehabilitation and Health Care failed to ensure one of its residents received adequate supervision to prevent the resident from leaving the facility. The citation specifically states that the resident had been identified as “at risk for elopement,” and eloped after being escorted to an appointment at the local hospital. According to the citation, a review of the hospital’s security camera recording revealed that the resident’s escort “was distracted and did not supervise [the resident] while they were both in the lobby area of the hospital,” at one point exiting the building for a period of ten minutes and leaving the resident alone. The facility’s plan of correction in response to the citation included the termination of the escort in question.

2.  The nursing home did not keep resident drug regimens free from unnecessary drugs. Section 483.45 of the Federal Code requires nursing homes to maintain “each resident’s drug regimen… free from unnecessary drugs.” An April 2017 citation describes the nursing home’s failure to ensure that residents using medication for an unspecified condition “receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.” The citation states specifically that the facility did not implement one resident’s pharmacist-recommended and physician-approved dose reduction for klonopin. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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