Articles Posted in Medication Errors

Central Island Healthcare has received 29 citations for being in violation of public health code since 2018 after a total of four surveys by state inspectors found deficiencies within the facility.

Central Island Healthcare received 29 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 15, 2022. The Plainview 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 protect residents from the unnecessary use of psychotropic medications. Section 483.45 of the Federal Code stipulates that nursing homes who have not used psychotropic medications should not be given them unless medically necessary. An August 2019 citation found that Central Island Healthcare failed to ensure such. The citation specifically describes a resident who was started on an unspecified antipsychotic medication “without any documented evidence of the clinical need for the medication.” The citation goes on to state that the medication’s administration frequency was increased from once a day to twice at day at the request of the resident’s family, and that the dosage was doubled “due to a medication error entry.” A plan of correction undertaken by the facility included the resident’s examination by a physician and a psychiatrist, after which the resident’s medication dosage was adjusted.

Sapphire Nursing and Rehab at Goshen has received 19 citations for being in violation of public health code since 2018 after multiple deficiencies were found during a total of 4 surveys by state inspectors.

Sapphire Nursing and Rehab at Goshen received 19 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Goshen 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 protect residents from the unnecessary use of psychotropic medications. Under Section 483.25 of the Federal Code, nursing homes must ensure resident drug regimens are free of unnecessary drugs, including psychotropic drugs. A December 2019 citation found that Sapphire Nursing and Rehab at Goshen failed to ensure such. The citation states specifically that there was a lack of documentation indicating the continued use of an antipsychotic drug by one resident. In an interview, the facility’s Registered Nurse Manager stated that the resident “did not have behavior issues” and that “non-pharmacalogical interventions had not been implemented prior to the start” of the anti-psychotic drug regimen. A plan of correction undertaken by the facility included the review of the resident’s medical record and the implementation of a gradual dose reduction.

The Willlows at Ramapo Rehabilitation and Nursing Center has received 23 citations for being in violation of public health code since 2018 after a total of 4 surveys by state inspectors found multiple deficiencies within the facility.

The Willows at Ramapo Rehabilitation and Nursing Center received 23 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Haverstraw 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 supervision to prevent elopement. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with a level of supervision necessary to prevent accidents. A September 2021 citation found that The Willows at Ramapo failed to ensure such. The citation specifically describes an incident in which the facility’s receptionist “left the front desk without coverage, leaving the front desk unattended,” after which a resident with severe cognitive impairment “was able to exit the facility undetected by staff.” The resident was later discovered in the parking lot by facility staff. A plan of correction undertaken by the facility included an audit of residents at risk of elopement to ensure the proper placement and functioning of their wander guard devices.

Williamsbridge Center for Rehabilitation and Nursing has received a total of 24 citations for being in violation of public health code since 2018 after state inspectors found multiple deficiencies within the nursing home.

Williamsbridge Center for Rehabilitation and Nursing has received 24 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on February 18, 2022. The Bronx 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-prevention measures. Under Section 483.80 of the Federal Code, nursing homes must create and maintain a program to prevent and control the development and transmission of disease. A May 2021 citation found that Williamsbridge Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically the facility’s contracted vendors did not wear proper personal protective equipment while in the room of a resident on contact and droplet precautions. The citation goes on to describe an instance in which a resident’s “indwelling catheter drainage bag was on the floor on multiple occasions.” A plan of correction undertaken by the facility included the education of the  vendors in question on hand-washing and PPE procedures, as well as the in-servicing of nursing staff on the positioning of drainage bags.