Articles Posted in Medication Errors

Northern Manhattan Rehabilitation and Nursing Center received 24 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on February 7, 2020. The Manhattan 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 keep medication error rates adequately low. Section 483.45 of the Federal Code requires nursing home facilities to maintain medication error rates below five percent. A March 2019 citation found that Northern Manhattan Rehabilitation and Nursing Center did not keep medication rates below that threshold. An inspector specifically found that one of the facility’s Licensed Practical Nurses did not administer medication to a resident as ordered, because it “was not in stock at the facility,” resulting in the resident never receiving their ordered daily dosage. The citation states that separately, another Licensed Practical Nurse administered a resident’s injectable medication through an incorrect route. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home did not implement adequate measures to investigate allegations of misconduct. Under Section 483.12 of the Federal Code, nursing homes are required to investigate, and provide evidence of investigations, any allegations of abuse, neglect, exploitation, or mistreatment. An April 2018 citation found that Northern Manhattan Rehabilitation and Nursing Center did not maintain evidence “that all alleged violations involving resident abuse by facility staff were reported to New York State Department of Health.” The underlying alleged violation was the report by a resident’s family member that a staff member “slapped the resident in her face,” which the citation states the facility failed to report to regulatory authorities in compliance with facility procedure stating that reports “must be made immediately upon having reasonable cause.” A plan of correction undertaken by the facility included the in-servicing of facility staff on relevant policy.

St. Mary’s Center received 26 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on February 7, 2020. The Manhattan 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 failed to prevent residents from taking unnecessary drugs. Section 483.45 of the Federal Code requires that nursing home facilities maintain “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that St. Mary’s Center did not ensure each of its residents drug regimens were free of unnecessary drugs. An inspector specifically found that one of its residents was administered a certain anti-psychotic medication “without a clear continued indication for use, and without an attempt at gradual dose reduction within the last year.” The citation states that the resident was documented as having intact cognition, “no mood or potential indicators” of a redacted medical condition, “no hallucinations and no delusions,” as well as “no physical or verbal… behaviors noted.” The citation also states that there was no documented evidence that the facility attempted to gradually reduce the resident’s medication dosage, in accordance with federal regulations. A plan of correction undertaken by the facility included the reduction of the medication and continued monitoring of the resident.

2. The nursing home failed to prevent residents from taking unnecessary psychotropic medications. Section 483.45 of the Federal Code also requires that nursing homes ensure residents are not administered unnecessary psychotropic medications, which the code defines as “any drug that affects brain activities associated with mental processes and behavior.” A September 2019 citation found that two residents at Saint Mary’s Home were prescribed psychotropic medications for a redacted condition “with no evidence of behaviors to support the ongoing use of” medication for that condition, and without any attempted gradual dose reductions within the previous two years. A plan of correction undertaken by the facility included the evaluation of both residents by a psychiatrist and attending physician, and the completion for one resident of a gradual dose reduction.

Northern Riverview Health Care 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 February 14, 2020. The Haverstraw 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 keep residents’ drug regimens free from unnecessary psychotropic medications. Section 483.45 of the Federal Code requires nursing homes to keep resident drug regimens free from medications that affect “brain activities associated with mental processes and behavior.” A November 2018 citation found that Northern Riverview Health Care Center did not ensure such. The citation specifically describes a resident for whom the facility did not implement a gradual dose reduction or provide sufficient documentation contra-indicating gradual dose reduction for the use of a medication to treat depression and another redacted disorder. A plan of correction undertaken by the facility included the evaluation of the resident by a psychiatrist and the discontinuation of the medication.

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 create and maintain “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” A November 2018 citation found that Northern Riverview Health Care Center did not take ensure such a program was maintained. An inspector specifically observed a resident caring for her tracheostomy tube with an improper technique and without using proper hand hygiene measures. In an interview, the resident stated that she had been taught to perform the activity by a doctor in a hospital rather than by facility staff. The citation states further that the resident’s care plan contained no evidence that facility staff trained the resident or attempted to train her to care for her device in a manner that would prevent the potential spread of infection and cross contamination. The citation describes this deficiency as having the “potential to cause more than minimal harm.”

The Valley View Center for Nursing Care and Rehabilitation received 43 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 five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not ensure an accident-free environment. Section 483.25 of the Federal Code requires nursing homes to keep resident environments “as free of accident hazards as is possible.” An August 2019 citation found that The Valley View Center for Nursing Care and Rehabilitation did not ensure such for two residents. The citation states specifically that a resident who was dependent on the assistance of two persons for bed mobility, toilet use, and transfer was transferred after restroom use by one person instead of two. The citation also states that another resident sustained a laceration to her leg while being transferred to her wheelchair from her bed with the assistance of a sliding board. A review of the incident found that the Certified Nursing Assistants who transferred the resident “were not trained prior to the date of the accident.” The citation states that these deficiencies had the “potential to cause more than minimal harm.”

2. The nursing home did not implement necessary steps to prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment.” An August 2019 citation found that The Valley View Center for Nursing Care and Rehabilitation did not provide such an environment. A surveyor specifically found that the nursing home did not ensure its potable water system receiving required testing for Legionella and other water-borne pathogens. The surveyor also found that facility staff did not follow “proper hand hygiene to prevent cross contamination and the spread of infection for 3 residents.” A plan of correction undertaken by the facility included the testing of the water system and the education of relevant staff on proper hand hygiene.

Highland Rehabilitation and Nursing Center received 33 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 Middletown 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 take adequate steps to prevent accidents. Under Section 483.25 of the Federal Code, nursing home facilities must “ensure that the resident environment remains as free of accident hazards as is possible; and [that] each resident receives adequate supervision and assistance devices to prevent accidents.” A March 2016 citation found that Highland Rehabilitation and Nursing Center did not ensure residents’ environment was sufficiently free of accident hazards, nor that two residents were provided adequate supervision. The citation states specifically that the facility did not implement measures “to minimize or prevent injuries relating to falling out of bed unto [sic] a hard surface” for one resident, and that the facility nursing staff did not ensure the other resident wore proper footwear to prevent falls. A plan of correction undertaken by the facility included the updating of the residents’ care plans with new interventions to prevent falls.

2. The nursing home did not meet food safety standards. Section 483.60 of the Federal Code states that nursing homes just “Store, prepare, distribute and serve food in accordance with professional standards for food service safety.” An April 2018 citation found that Highland Rehabilitation and Nursing Center did not ensure the food items in “nourishment refrigerators” in certain nursing unites “were stored in accordance with acceptable standards.” The citation states specifically that food in one fridge was not labeled with a resident’s name and was outdated, in contravention of facility policy; that another food item was labeled with a name but not dated; and that outdated food was also present in the fridge. A plan of correction undertaken by the facility included the discarding of the outdated and undated food.

A Holly Patterson Extended Care Facility 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 14, 2020. The Uniondale nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The facility did not protect residents’ right to be free from the use of unnecessary psychotropic medications. Under Section 483.45 of the Federal Code, nursing homes must ensure that “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record,” and, among other things, that facilities attempt non-pharmacological interventions before administering such drugs. An October 2019 citation found that A Holly Patterson Extended Care Facility did not ensure this right for one resident. The citation states specifically hat the resident was ordered to be administered a redacted psychotropic medication, although there was “no documented evidence of non-pharmacological interventions attempted prior to the start of the antipsychotic medication.” A plan of correction undertaken by the facility included the in-servicing of the facility’s social worker and some nurses.

2. The nursing home did not implement proper measures to prevent and control the spread of infection. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program” that ensure residents a safe, sanitary environment. A June 2018 citation found that A Holly Patterson Extended Care Facility did not ensure such. The citation specifically states that an observer found that for four of the facility’s resident use buildings with potable water systems, the facility “did not conduct water sampling for Legionella quarterly as recommended by their Water Management Plan.” In an interview, the facility’s Vice President of Facilities indicated that he would contact the facility’s water management company to ensure regular testing in the future. The citation states that this deficiency had the “potential to cause minimal harm.”

Rockville Skilled Nursing & Rehabilitation Center received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 14, 2020. The Rockville Centre 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 adequately treat and care for residents’ pressure ulcers and bedsores.  Section 483.25 of the Federal Code requires nursing homes ensure that residents with pressure ulcers receive “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure one resident with pressure ulcers received such. The citation states specifically that although a nurse noted the resident’s bilateral heels had “discoloration and were soft and tender,” the Registered Nurse’s full assessment of that resident’s heels “was not relayed to the physician in a timely manner, resulting in a delay in treatment.” In an interview, the Registered Nurse Supervisor stated that she had assessed the resident and documented her findings, but “forgot to write a progress note,” and then passed the findings to a wound nurse. In an interview, that nurse stated that she told the RN supervisor that a note had to be put in the resident’s medical record, and further that told the facility’s Assistant Director of Nursing Services about the resident’s condition, who “wanted to wait for the progress note to be written.”

2. The nursing home did not take adequate measures to prevent residents from being administered unnecessary psychotropic drugs. Section 483.45 of the Federal Code requires nursing homes to ensure that “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure residents taking medication for a redacted condition received gradual dose reductions, “unless clinically contraindicated, in an effort to discontinue these drugs.” The citation specifically describes one resident who was prescribed an antipsychotic medication, Quetiapine, and whose psychiatrist and pharmacy consultant “both recommended a tapering of the medication.” However, according to the citation, “there was no documented evidence that the physician took any action” to implement this recommendation. A plan of correction undertaken by the facility included the implementation of the drug’s dose reduction.

Sands Point Center for Health and Rehabilitation received 35 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 15, 2020. The Port Washington 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 provide adequate pressure ulcer care and treatment. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with pressure ulcers “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A July 2018 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for one resident. The citation states specifically that “there was no documented evidence that a skin condition to the sacrum was assessed or received treatment until five days after the resident was admitted to the facility.” In an interview, the facility’s wound nurse stated that she had not seen the resident until several days after a note was left for her about the wound, and that “the wound should have been treated sooner.” The facility’s Medical Doctor stated further, in an interview, that “the doctor should have been called over the weekend and a treatment initiated.”

2. The nursing home did not take adequate measures to protect residents from the use of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes are required to keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for three residents. The citation goes on to state specifically that one resident was administered an antipsychotic medication despite an absence of any “documented justification or attempts at non-pharmacological intervention”; that another resident was administered an antipsychotic medication without an appropriate diagnosis and that a third resident was administered multiple drugs, including an antipsychotic, without an appropriate psychiatric diagnosis. The citation states that this deficiency had the “potential to cause more than minimal harm” to residents.

South Shore Rehabilitation and Nursing Center received 43 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 16, 2020. The Freeport nursing home’s citations resulted from a total of 10 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately keep residents free from medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure residents are “free of any significant medication errors.” A February 2019 citation found that South Shore Rehabilitation and Nursing Center did not ensure such for one resident. The citation states specifically that the resident did not receive four doses of an anti-arrhythmic medication, as ordered by their physician. In an interview, the facility’s Director of Nursing stated that “the medication was not available for the resident, and the MD was not notified of the unavailability of the medication.” The citation states the deficiency had the “potential to cause more than minimal harm.”

2. The nursing home did not implement adequate accident prevention measures. Section 483.25 of the Federal Code requires nursing homes to ensure that resident environments are as free as possible of accident hazards, and that residents received “adequate supervision and assistance devices to prevent accidents.” A March 2016 citation found that South Shore Rehabilitation and Nursing Center did not ensure a resident identified as at risk for falls was provided adequate supervision assistance devices. The citation states specifically that while the resident’s care plan documented a chair alarm as one of their fall-prevention interventions, an inspector observed the resident without the chair alarm in place. In an interview, one of the facility’s charge nurses stated that she did not know why the alarm was not in place; in a separate interview, a Certified Nursing Assistant stated that the resident “was supposed to have a chair alarm but she forgot to place it on her as she was in a hurry” to get the resident to therapy.

Sunharbor Manor 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 16, 2020. The facility has also been the subject of a 2010 fine of $10,000 in connection to findings that it violated health code provisions regarding quality of care. The Roslyn Heights 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 adequately protect residents from abuse. Section 483.12 of the Federal Code ensures nursing home residents the right to freedom from abuse. A July 2019 citation found that Sunharbor Manor did not ensure this right for one resident. The citation states specifically that when a Licensed Practical Nurse approached the resident “from behind and injected him with a syringe through his long-sleeved shirt,” the resident responded with agitation and “tried to hit the nurse,” resulting in the nurse pushing the resident “to the floor causing him to fall sideways in his wheelchair and then to the floor.” In an interview, the facility’s Director of Nursing stated that an investigation she conducted ended in the conclusion that “there was possible abuse.” A plan of correction undertaken by the facility included the termination of the nurse.

2. The nursing home did not adequately protect residents from the administering of unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” A February 2017 citation found that Sunharbor Manor did not ensure one resident’s drug regimen “had adequate indications for its use.” The citation states specifically that the resident, who “had no mood or behavior problems” but did have short- and long-term memory problems, received an antipsychotic and antidepressant medication, although the facility’s Psychiatrist stated that “age related cognitive decline was not the appropriate indication” for one of the medications. A plan of correction undertaken by the facility included the review and revision if necessary of its policy and procedure on antipsychotic medication.

Contact Information