Articles Posted in Medication Errors

Woodhaven Nursing Home received 46 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 two fines: one 2017 fine of $2,000 in connection to findings in an inspection that it violated health code provisions regarding unnecessary; and one 2016 fine of $12,000 in connection to findings in a 2013 inspection that it violated health code provisions regarding accidents and administration. The Port Jefferson Station 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 prevent abuse. Section 483.12 of the Federal Code states that nursing home residents have the right to be free from abuse. A November 2019 citation found that Woodhaven Nursing Home did not ensure that right for one resident. The citation states specifically that the resident was repeatedly hit by another resident “with a wheelchair with the leg rest in place,” suffering a “laceration with severe bleeding to the right leg” and requiring transfer to the hospital. A plan of correction undertaken by the facility included the transfer of the resident to a “safe location” and the transfer of the aggressive resident to a hospital for psychiatric evaluation.

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Pinnacle Multicare 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 April 24, 2020. The facility has also received a 2012 fine of $18,000 in connection to findings in a 2011 inspection that it violated health code provisions regarding abuse, accidents, nutrition, and nurse aid competency; and a 2011 fine of $4,000 in connection to findings in a 2009 inspection that it violated health code provisions regarding quality of care and nutrition. The Rye nursing home’s citations resulted from a total of five inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not protect residents from the administration of unnecessary drugs. Section 483.25 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs.” An April 2016 citation found that Pinnacle Multicare Nursing and Rehabilitation Center did not ensure such for one resident. The citation states specifically that the resident continued to receive sliding scale insulin coverage even after this treatment was discontinued. In an interview, the resident’s physician stated that the resident’s monitoring order “should have been changed when the order for the sliding scale insulin was discontinued.” The citation states that this deficiency had the “potential to cause more than minimal harm.”

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Martine Center for Rehabilitation received 30 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. The White Plains nursing home’s citations resulted from a total of three inspections by state surveyors. The violations 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 requires nursing home facilities to provide an environment as free as possible from accident hazards, and with adequate supervision and assistive devices to prevent accidents. A June 28, 2018 inspection found that a resident who suffered a fall resulting in an injury had not been provided with non-skid socks, as her plan of care directed. She was considered “at risk for falls secondary to impaired mobility and functional status,” and after a 2017 fall, staff members were directed to ensure she wore non-skid socks at all times. After a later incident in which she fell while trying to go to the bathroom, an inspector found, the subsequent investigation “did not address whether the resident was wearing the appropriate footwear” or if staff were implementing her plan of care properly to ensure such. The inspector found that this lapse resulted in the “potential to cause more than minimal harm.”

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Luxor Nursing and Rehabilitation at Sayville received 34 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 3, 2020. The facility has also received two fines: one 2011 fine of $10,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding pressure ulcers, and one 2010 fine of $10,000 in connection to findings in a 2009 inspection that it violated health code provisions regarding quality of care. The Sayville 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 adequately implement measures to treat and care for residents with bedsores / pressure ulcers. Under Section 483.25 of the Federal Code, nursing homes must ensure residents with pressure ulcers are provided “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A November 2018 citation found that Luxor Nursing and Rehabilitation at Sayville did not ensure such for one resident. The citation states specifically that there was “no documented evidence that the resident’s heels were being offloaded and no documented evidence of timely follow-up after the resident complained about right heel pain,” and that the resident developed a Stage II pressure ulcer on their right heel. A plan of correction undertaken by the facility included the in-servicing of a staff nurse regarding how to communicate a patient’s wound development to the wound care nurse.

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Maria Regina Residence 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 4, 2020. The Brentwood 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 care for bedsores / pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to ensure that residents with pressure ulcers receive necessary treatment and care. A May 2019 citation found that Maria Regina Residence did not ensure such for one resident. The citation states specifically that the resident developed a Stage II pressure ulcer on their right heel, but that there was “no documented evidence of monitoring of the pressure ulcer” for a several week-long period after its development. In an interview, the facility’s Director of Nursing Services stated that she “could not commented why the wound care team had not been following the resident’s heel ulcer.” A plan of correction undertaken by the facility included the in-servicing of all licensed nurses and the addition of the resident’s pressure ulcer to the wound management section of their medical record.

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Momentum at South Bay for Rehabilitation and Nursing 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 5, 2020. The facility has also received a 2016 fine of $4,000 in connection to findings in a 2015 inspection that it violated health code provisions regarding quality of care and facility administration. The East Islip 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 stipulates that nursing home facilities must ensure that residents with pressure ulcers receive care that is “consistent with professional standards of practice.” A September 2018 citation found that Momentum at South Bay for Rehabilitation and Nursing did not ensure such for three residents. The citation states specifically that the facility did not perform a “thorough assessment” of one resident’s Stage IV pressure ulcer when it was first identified; that “there was no documented evidence” that a resident’s “dry scabbed area to the left posterior ankle” was provided daily monitoring, or that a protective dressing was applied when it worsened and that a third resident was admitted with a Stage II pressure ulcer which was not “properly assessed until three days after admission.” The citation states that these deficiencies had the “potential to cause more than minimal harm.”

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Luxor Nursing and Rehabilitation at Mills Pond received 20 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 3, 2020. The facility has also received a 2017 fine of $10,000 in connection to findings in a 2017 inspection that it violated unspecified health code provisions. The St. James 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 take adequate measures to treat and care for pressure ulcers. Section 483.25 of the Federal Code specifies that nursing homes must ensure residents with pressure ulcers receive “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” A June 2016 citation found that Luxor Nursing and Rehabilitation at Mills Pond did not ensure such for one resident. The citation states specifically that the resident’s medical record “lacked individualized care specific to the resident who was at risk for developing” pressure ulcers and that interventions “that were in place were not provided.” The resident later developed two pressure ulcers, according to the citation, which states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the re-education of the nurse assigned to the resident in question. Continue reading

Hilaire Rehab & Nursing received 72 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 3, 2020. The facility has also received two fines: a 2019 fine of $10,000 in connection to findings in a 2019 inspection that it violated unspecified health code provisions; and a 2016 fine of $12,000 in connection to findings in a 2015 inspection that it violated health code provisions regarding quality of care and notification of changes. The Huntington 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) treatment and care. Under Section 483.25 of the Federal Code, nursing homes must ensure that residents with pressure ulcers are provided “necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.” An October 2018 citation found that Hilaire Rehab & Nursing failed to ensure such for two residents. The citation states specifically that the facility did not complete a pressure ulcer risk assessment upon a resident’s admission, and as such did not implement the use of heel pressure devices, leading to the resident’s development of a Stage II pressure ulcer on their left heel, which later deteriorated into a Stage IV pressure ulcer. The citation states further that the facility “did not fully assess and monitor” a second resident’s pressure ulcer, or make use of a specialty mattress to promote healing, and as such the resident’s ulcer deteriorated to a Stage III wound. The citation concludes that these deficiencies resulted in “actual harm” to the residents in question.

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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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