Articles Posted in Medication Errors

A new analysis by City and State asks whether New York’s nursing home facilities are prepared for another wave of the Covid-19 pandemic. Noting that while long-term care facilities have so far accounted for about 8% of Covid-19 cases, they have comprised about 40% of US fatalities from the disease. In New York especially, there have been 27,307 total Covid-19 deaths, of which 6,967 confirmed or presumed Covid-19 fatalities took place in nursing home facilities, a number that excludes residents who died outside of the facility. While nursing homes have improved their policies and procedures when it comes to Covid-19 since the virus initially struck, City and State argues, “there are still vulnerabilities that could leave nursing-home residents and staff at risk again.”

On the positive side, nursing homes are more likely to have more consistent access to tests and personal protective equipment, the analysis suggests. Nursing homes have already been conducting regular testing of all employees, and are required to have a 60-day supply of PPE. Additionally, a state rule has been reversed that in the spring led to nursing homes accepting Covid-19 patients from hospitals, spreading the virus throughout facilities.

Continue reading

Bensonhurst Center for Rehabilitation and Healthcare suffered 10 confirmed Covid-19 deaths and 27 presumed Covid-19 deaths as of November 23, 2020, according to state records. The nursing home received 25 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on November 23, 2020. The Brooklyn 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 sanitary food services. Section 483.60 of the Federal Code requires nursing homes to “procure food from sources approved or considered satisfactory by federal, state or local authorities” and ensure food is stored in compliance with professional standards of practice. A February 2020 citation found that Bensonhurst Center for Rehabilitation and Healthcare failed to ensure such. The citation states specifically that the facility did not ensure its food service workers performed hand hygiene before they handled food. An inspector also observed a meat slicer that “was not properly cleaned after use.” The citation goes on to state that despite the nursing home’s policies stating “gloves must be changed or removed before starting another job and Don’t forget always wash hands when you change gloves before starting another job,” a dietary aide “was observed touching the trash can lid without gloves as he discarded empty metal pudding cans,” then donning cleaning gloves, cleaning the tilt skillet, removing his gloves, and discarding leftover food without washing his hands first. The Aide was observed handling various other items and scooping cereal into a paper cup without first washing his hands. A second dietary aide was observed cleaning the meat slicer without removing its sharpener blade, on which meat debris was observed after the cleaning. A plan of correction undertaken by the facility included the in-servicing of kitchen staff. Continue reading

Huntington Living Center has received 38 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The Waterloo 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 take adequate measures to prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must create a resident environment as free as possible from accident hazards, and with adequate supervision to prevent accidents. A February 2020 citation found that Huntington Living Center did not ensure such. The citation states specifically that a resident smoked in an area that was not designated for smoking, and the resident was further storing their own lighter. The citation goes on to state that the resident’s smoking supplies were supposed to be stored in the nurse’s unit, and that the resident was supposed to smoke off-property at the far side of a parking lot. In an interview, the resident stated that “they were supposed to smoke over on the next street by the church, but it was further away,” and that “they try to remember to lock the lighters up but they do not always remember to do that.” A plan of correction undertaken by the facility included a review of the facility’s smoking policies and protocols.

2. The nursing home did not adequately prevent infection. Under Section 483.80 of the Federal Code, nursing home facilities are supposed to endeavor to prevent and control infections via an infection control program. A February 2020 citation found that Huntington Living Center did not ensure such. The citation states specifically that the nursing home’s employees “did not follow appropriate infection control techniques or hand hygiene” for three residents reviewed for blood glucose testing and wound infections. It goes on to state that a blood sugar monitoring device was not properly cleaned after three resident uses, and that appropriate hand hygiene was not followed for another resident. A plan of correction undertaken by the facility included the re-education of relevant staff.

Steuben Center for Rehabilitation and Healthcare has received 38 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received a 2018 fine of $10,000 in connection to findings in a 2017 inspection that it violated unspecified health code provisions. The Bath 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 protect residents from abuse. Section 483.12 of the Federal Code grants nursing home residents “the right to be free from abuse.” A January 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for one resident. The citation states specifically that a Licensed Practical Nurse was witnessed undressing and washing the resident after the resident told the LPN to stop, then pushing the resident onto the toilet when the resident attempted to stand up. The citation also states that the LPN told another nurse at the facility “that she wanted to use the biggest needle she could find on the resident.” A plan of correction undertaken by the facility included the suspension and subsequent termination of the LPN.

2. The nursing home did not properly prevent infection. Section 483.80 of the Federal Code stipulates that nursing homes must maintain a program to prevent and control infection. A July 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for two residents. The citation states specifically that a nurse “did not properly disinfect the blood glucose testing machine (glucometer) before or after resident use.” In an interview, the nurse said “she should have wiped the glucometer down between residents” and that “she usually cleans the glucometer with bleach wipes that are located at the nurses’ station.” The facility’s Assistant Director of Nursing said in another interview that “she would expect the nurse to clean the glucometer in between residents using the approved bleach wipes.”

Oak Hill Rehabilitation and Nursing Care Center has received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The Ithaca 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 significant medication errors. Under Section 483.25 of the Federal Code, nursing homes must ensure residents “are free of any significant medication errors.” A February 2020 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for three medications. The citation states specifically that the residents “did not receive significant medications as ordered.” A plan of correction undertaken by the facility included the administration to two residents of their missed doses, and an RN Assessment of all three residents, one of whom was already discharged.

2. The nursing home did not properly prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to create and maintain a program designed to ensure residents a safe and sanitary environment via the maintenance and control of infection. A February 2019 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for one resident. The citation states specifically that the resident’s catheter bag and tubing were resting directly on the facility’s floor, in violation of health policy. It goes on to state that the facility’s washers and dryers “were not maintained according to user manual,” and that “There was no documented facility policy for the maintenance of the washers and dryers.” A plan of correction undertaken by the facility included the placement of the resident’s catheter in a labeled basin, and the required maintenance of the washers and dryers.

Kendal at Ithaca has received 16 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The Ithaca 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 accidents. Under Section 483.25 of the Federal Code, nursing homes must ensure resident environments are “as free of accident hazards as is possible.” A July 2016 citation found that Kendal at Ithaca did not ensure such. The citation states specifically that the facility’s hot water was too hot. It goes on to describe “the hot water temperature [that] was determined to be over 120 degrees Fahrenheit.” It states further that a Hot Water Return Status form “did not document any action taken after the hot water that was found to be too hot,” and “no documented evidence elsewhere that any action was taken to reduce the hot water temperature after it was determined to be too hot.” A plan of correction undertaken by the facility included adjustments to the mixing valves in the affected units.

2. The nursing home did not adequately comply with food safety standards. Under Section 483.35 of the Federal Code, nursing homes must store and prepare food under sanitary conditions. A July 2016 citation found that Kendal at Ithaca did not ensure such in two of its four kitchens. The citation states specifically that “spoiled and outdated foods were stored in the cafeteria walk-in refrigerator” and that an employee tested the sink’s sanitizer concentration using “an unapproved method.” The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the discarding of spoiled and outdating food and the re-education of the employee in question.

Groton Community Health Care Center Residential Care Facility has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $20,000 in connection to findings that it violated health code provisions regarding equipment conditions, pressure sore care, accidents, and administrative practices. The Groton 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 comply with infection control practices and procedures. 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 and to help prevent the development and transmission of communicable diseases and infections.” A January 2019 citation found that Groton Community Health Care Center Residential Care Facility did not ensure such. The citation states specifically that facility staff did not perform hand hygiene while changing a resident’s wound pressure ulcer wound dressing. The citation goes on to describe a Licensed Practical Nurse who, while treating the resident’s wound, “removed her soiled gloves after removing the old dressing, then immediately donned another pair of gloves without performing hand hygiene.” In an interview, the nurse said “she should have performed hand hygiene between glove changes.” In another interview, the facility’s infection control nurse said that “she expected staff to perform hand hygiene after removing and before replacing gloves when completing a dressing change.”

2. The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes must keep residents “free of any significant medication errors.” A May 2018 citation found that Groton Community Health Care Center Residential Care Facility failed to ensure such for one resident. It goes on to describe specifically a resident who “was not consistently provided with her heart medication as ordered and the facility did not identify the root cause to prevent reoccurrence.” A plan of correction undertaken by the facility included the review and revision of the facility’s medication error policy and the provision of a monthly review of medication error’s to the facility’s QAA committee and Medical Director.

Cayuga Nursing and Rehabilitation Center has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $36,000 in connection to findings that it violated health code provisions concerning resident rights, accidents, quality of care, pressure ulcers, food standards, administrative practices, and more. The Ithaca 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 infection-control procedures. Section 483.80 of the Federal Code stipulates that nursing homes must create and maintain an infection control program so as to stave off the development and transmission of disease. A June 2019 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such. The citation describes the facility’s staff’s failure to “follow proper infection control technique during a skin treatment observation,” specifically describing failures to wipe down equipment, perform hand hygiene, and use proper equipment. The equipment goes on to state that the facility did not employ proper infection control technique while administering medication to seven residents, specifically describing a nurse who did not perform hand hygiene between each resident’s medication administration. A plan of correction undertaken by the facility included the re-education of the nurse in question.

2. The nursing home did not employ adequate measures to care for pressure ulcers. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with necessary treatment and services to prevent and/or heal pressure ulcers. A December 2017 citation found that Cayuga Nursing and Rehabilitation Center did not ensure such for one resident. The citation specifically describes a resident who was identified on admission as having a Stage II pressure ulcer, but “was not re-assessed timely and she was not provided with pressure relief interventions as planned to promote healing.” A plan of correction undertaken by the facility included the education of relevant staff and the revision of the resident’s plan of care.

East Side Nursing Home has received 11 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Warsaw 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. Under Section 483.25 of the Federal Code, nursing homes are required to “ensure that residents are free of any significant medication errors.” A September 2016 citation found that East Side Nursing Home failed to ensure such for three residents. The citation is heavily redacted but indicates “issues” that involved the administration of a medication “and signing for another dosage” to one resident, as well as “interim physician orders” for two other residents. It goes on to describe confusion involving the physician’s orders for one resident, and the administration of a significant medication without an order. A plan of correction undertaken by the facility included the review of physician’s orders for each of the residents.

2. The nursing home did not implement adequate measures to prevent infection. Section 483.80 of the Federal Code requires the establishment and maintenance by nursing home facilities of “an infection prevention and control program designed to provide a safe, sanitary and comfortable environment” for residents. A January 2018 citation found that East Side Nursing Home did not ensure such. The citation specifically describes the facility’s failure to “conduct water sampling for Legionella every 90 days for the first year of their sampling plan.” According to a review of the nursing home’s sampling reports, only two samples had been taken in its potable water system during the year in question. In an interview, the facility’s Supervising Administrator “stated that the sampling company was supposed to come in and sample in December, but they did not make it.” A plan of correction undertaken by the facility included the drafting of a policy and procedure to “address the management of the legionella testing compliance.”

Penn Yan Manor Nursing Home has received 14 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 14, 2020. The Penn Yan nursing home’s citations resulted from a total of two 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 requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” A November 2019 citation found that Penn Yan Manor Nursing Home failed to ensure such for one resident. The citation states specifically that the resident did not receive adequate supervision to prevent her from eloping from the facility undetected and falling outside, after which her care plan “was not revised to include an actual elopement.” The citation goes on to describe the nurse turning off an alarm at the nurse’s station, after which the resident exited the facility undetected, and later being found sitting on the ground by a staffer from a “neighboring facility,” who brought her back. In an interview, the nurse in question said “she thought she was resetting the alarm at the nurses’ station when she turned it off.” A plan of correction undertaken by the facility included the re-education of staff on the nurses’ station alarm system.

2. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code stipulates that nursing homes must ensure their medication errors rates do not meet or exceed five percent. A November 2019 citation found that Penn Yan Manor Nursing Home did not ensure such for two residents. The citation states specifically that one resident’s eye drops “were administered in both eyes instead of one eye,” and the other “had a medication ordered after meals that was given over an hour after meals.” A plan of correction undertaken by the facility included the re-education of nurses on medicine administration and the disciplining of one nurse.

Contact Information