Articles Posted in Medication Errors

Van Duyn Center for Rehabilitation and Nursing suffered 13 coronavirus deaths as of May 17, 2020, per state records. The nursing home also received 78 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on May 18, 2020. The facility has additionally received seven enforcement actions, including: a 2019 fine of $2,000 in connection to findings in a 2015 inspection that it violated unspecified health code provisions; a 2018 fine of $10,000 in connection to findings in a 2015 inspection that it violated unspecified health code provisions; and a 2016 fine of $40,000 in connection to findings that it violated health code provisions regarding transfer and discharge requirements, discharge, quality of care, and staff treatment of residents. The Syracuse nursing home’s citations resulted from a total of 14 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not take adequate measures to prevent infection. Section 483.80 of the Federal Code requires nursing homes to maintain an infection control program that ensures residents a sanitary environment. A January 2017 citation found that Van Duyn Center for Rehabilitation and Nursing did not ensure such. The citation states specifically that two employees “did not receive the flu vaccine, did not sign a declination of influenza vaccination, and were observed wearing their flu masks incorrectly.” The citation goes on to state that eight other employees wore their flu masks incorrectly, “potentially exposing residents and staff to influenza.” The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Central Park Rehabilitation And Nursing Center suffered eight coronavirus deaths as of May 17, 2020, according to state records and local news reports. The nursing home received 15 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on May 18, 2020. The facility has also received three enforcement actions: a 2018 fine of $4,000 in connection to findings in a 2015 inspection that it violated unspecified health code provisions; a 2016 fine of $12,000 in connection to findings in a 2015 inspection that it violated health code provisions regarding pressure ulcers and quality of care; and a 2010 fine of $2,000 in connection to findings in a 2009 inspection that it violated health code provisions regarding infection control. The Syracuse 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 maintain its infection control program. Section 483.80 of the Federal Code stipulates that nursing homes must “establish and maintain an infection prevention and control program” to prevent the development and transmission of disease and infection. A January 2020 citation found that Central Park Rehabilitation And Nursing Center did not ensure such a program was properly maintained. The citation states specifically that one of the facility’s Licensed Practical Nurses failed to conduct proper hand hygiene before administering medication to a resident. In an interview, the nurse stated that she knew she did not perform proper hand hygiene, and that hand hygiene should have been performed before she administered the resident’s medication, so as to prevent the spread of infection and flu. The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Surge Rehabilitation and Nursing received 30 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 15, 2020. The Middle Island 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 employ adequate accident-prevention measures. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents receive adequate supervision and assistance devices to prevent accidents. A July 2018 citation found that Surge Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the facility did not follow the resident’s dentist’s recommendations regarding the safe use of a denture. In an inspection, according to the citation, the resident was talking to a nursing assistant, and as they spoke, “the upper denture appeared loose and moved with her lip and tongue movement.” The citation goes on to describe a nurse stating that although the resident’s dentures “are supposed to come out at night and [be] replaced in the morning,” the resident does not always allow staff to remove them; another staffer stated that “sometimes the resident has the denture in from the previous night and refuses to use adhesives for dentures.” In an interview, the resident’s dentist stated that “removing the denture at night is a standard precaution,” and that the resident’s smaller-than-conventional denture may pose a remote risk of aspiration.

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The Hamlet Rehabilitation and Healthcare Center at Nesconset received 37 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 19, 2020. The Nesconset 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 protect residents from abuse. Section 483.12 of the Federal Code requires nursing homes to “Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.” A September 2018 citation found that The Hamlet Rehabilitation and Healthcare Center at Nesconset did not ensure such for one resident. The citation states specifically that the resident in question “reported allegations of sexual and verbal abuse to facility staff,” and these allegations were not “promptly reported” to administrative authorities and investigated until the following day. in an interview, the facility’s social worker said that although she usually interviews residents making such allegations as soon as possible, “she was not made aware of any of the resident’s allegations of abuse” on the day they were made, instead learning of them at a staff meeting the following morning. A plan of correction undertaken by the facility included the in-servicing of relevant staff.

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A new report by the Long Term Community Care Coalition asks the question: “Can animals in a zoo or kennel expect better treatment and conditions than that which many human nursing home residents actually receive?” Noting that its goal is not to trivialize the experiences of nursing home residents or animals, the report seeks to demonstrate how nursing homes are subject to systemic accountability failures, resulting in rampant abuse and neglect that “not only fall below the federal nursing home standards of care, but also below accepted standards for the humane treatment of animals.”

The report compares conditions in eleven key areas of interest: freedom from abuse and neglect; general care and treatment; sufficient staffing with appropriate skills and competencies; nutrition and hydration; safe food handling; medical supervision; simulating and safe environment; freedom from restraints; treatment of injuries; appropriate medications; and infection control and prevention. Below is what the LTCCC found in each of those categories.

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Smithtown Center for Rehabilitation & Nursing Care received 11 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 10, 2020. The Smithtown 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 implement adequate accident prevention measures. Section 483.25 of the Federal Code states that nursing homes must provide residents with “adequate supervision and assistance devices to prevent accidents.” An August 2019 citation found that Smithtown Center for Rehabilitation & Nursing Care did not ensure such for one resident. The citation states specifically that an inspector observed the resident’s medications “observed left on the bedside table and… signed as administered by the Medication Licensed Practical Nurse.” According to the citation, the resident’s care plan contained no plan for self-administering of medications, and the LPN stated in an interview that she had left the room because she was called to assist another resident, although “she knows that she is not supposed to leave medications with the residents.”

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The Hamptons Center for Rehabilitation and Nursing received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The Southampton 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 prevent medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure residents “are free of any significant medication errors.” A June 2017 citation found that The Hamptons Center for Rehabilitation and Nursing did not ensure such for one resident. The citation states specifically that the resident received was administered the wrong dose of an anti-arrhythmic agent for ten days In an inspection, a Licensed Practical Nurse was observed preparing to administer the resident a pill from a blister packet labeled 400 milligrams. When informed by a surveyor that the physician’s orders were for the resident to receive a different dosage, and asked why there was a 400 milligram blister pack on the medication cart along with a 200 milligram blister pack, the LPN stated that the larger packet “was discontinued and should not have been on the cart.” A plan of correction undertaken by the facility included the removal of the 400 milligram blister pack and the education and disciplinary counseling of involved nursing staff.

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Suffolk Center for Rehabilitation and Nursing received 51 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 15, 2020. The facility has also received two fines: one 2017 fine of $10,000 in connection to findings in a 2016 inspection that it violated health code provisions regarding quality of care; and one 2016 fine of $10,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding quality of care. The Patchogue 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 maintain low enough medication error rates. Section 483.45 of the Federal Code requires nursing home facilities to ensure medication error rates below five percent. A December 2018 citation found that Suffolk Center for Rehabilitation and Nursing did not ensure a low enough rate. The citation states specifically that an inspector observed two errors out of 27 opportunities in a medication pass, leading to an error rate of 7.4 percent. The citation goes on to state that a Licensed Practical Nurse crushed a resident’s medication tablets whose blister packets stated “Do Not Crush.” In an interview, the LPN stated that she had not read the instructions. The facility’s consultant pharmacist stated in an interview that when crushed, one of the medications causes a bitter taste and may cause diarrhea, while the other would be more difficult to swallow. A plan of correction undertaken by the facility included the in-servicing of the facility’s medication nurses.

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Waters Edge Rehab & Nursing Center at Port Jefferson received 21 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 24, 2020. The facility has also received three fines: a 2019 fine of $2,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions; a 2016 fine of $10,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding accidents and supervision; and a 2016 fine of $4,000 in connection to findings in a 2012 inspection that it violated health code provisions regarding accidents and administration. The Port Jefferson 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 supervise residents. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with adequate supervision to prevent accidents. An October 2018 citation found that Waters Edge Rehab & Nursing Center at Port Jefferson did not ensure such for one resident. The citation states specifically that the resident “was left unsupervised on an outside patio in direct sunlight with external temperature at 85 degrees Fahrenheit for at least an hour and 15 minutes.” As a result, according to the citation, the resident suffered heat exhaustion and dehydration, and needed to be administered intravenous fluid. The citation states that this incident resulted in “actual harm” to the resident.

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Westhampton Care 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 April 24, 2020. The facility has also received a 2019 fine of $10,000 in connection to findings in a 2018 inspection that it violated unspecified health code provisions. The Westhampton 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 protect residents from neglect. Section 483.12 of the Federal Code ensures provides nursing home residents the right to freedom from abuse and neglect. A September 2018 citation found that Westhampton Care Center did not ensure such for one resident. The citation states specifically that the resident required the use of a mechanical lift device for transfers between surfaces. However, on one instance, two Certified Nursing Assistants transferred the residents without the use of the lift, and the resident subsequently “fell to her knees.” The CNAs did not report the incident to authorities, according to the citation, nor the resident’s “complaint of pain.” Afterward, the resident was transferred to a local hospital. A plan of correction undertaken by the facility included the suspension pending investigation of both CNAs.

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