Articles Posted in Medication Errors

Forest View Center for Rehabilitation and Nursing Cited received 20 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Forest Hills nursing home’s citations resulted from a total of three inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not keep residents free from significant medication errors. Under Section 483.45 of the Federal Code, nursing home residents have a right to be “free of any significant medication errors” in their drug regimens. An August 2016 citation found that the nursing home failed to comply with this section in an instance in which a resident was administered an unidentified antipsychotic medication after it was ordered to be discontinued and replaced with another medication; instead, the resident was administered both. In an interview, the facility’s Medical Director stated that the resident “should not have been receiving two antipsychotic medications daily.”

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Silvercrest received 19 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 13, 2019. The Jamaica nursing home’s citations resulted from a total of four inspections by state authorities. The violations they describe include the following:

1. The nursing home did not take adequate measures to prevent residents from sustaining falls. Section 483.25 of the Federal Code requires nursing homes to ensure that residents receive supervision to prevent them from sustaining accidents. According to a September 2018 citation, Silvercrest did not adequately supervise one resident, resulting in the resident falling. An inspector specifically found that the resident, who had been “assessed as a high risk for falls,” was left unattended in one of the facility’s hallways, and sustained a fall. When the resident was found by staff, she was observed suffering from “pain and swelling of the left shoulder” and transferred to a local hospital for examination.

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Park Gardens Rehabilitation & Nursing Center received 38 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 21, 2019. Those citations number six more than the statewide average of 32. The Bronx nursing home’s citations resulted from a total of three inspections by state authorities. The violations they describe include the following:

1. The nursing home did not ensure its residents’ drug regimens were free from unnecessary drugs. Section 483.45 of the Federal Code stipulates that nursing homes must maintain “each resident’s drug regimen… free from unnecessary drugs,” going on to clarify that “unnecessary” refers to any drug used in excessive dosage, for excessive duration, without adequate monitoring or indications, and/or in the presence of adverse consequences. A March 2017 citation found that Park Gardens Rehabilitation and Nursing Center failed to comply with this section in two separate capacities. In one, the facility did not provide “adequate monitoring” of a diabetic resident who had recently received an increase in their insulin dosage, so as to figure out whether the increase was effective or yielded any ill effects. Separately, the citation notes, the nursing home increased another resident’s dosage of an unidentified medication “without documentation for the reason of the increase.” The citation states that these failures resulted in the “potential to cause more than minimal harm” to residents.

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King Street Home received 32 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Port Chester nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did take adequate steps to protect residents from abuse. Under Section 483.12 of the Federal Code nursing homes must ensure residents’ “right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A July 2019 citation found that King Street Home did not ensure residents’ right to be free from abuse in an instance where a Certified Nursing Assistant was accused of being “rough” with a resident. After the resident reported the allegation, the assistant was removed from contact with that resident, but was not promptly removed from contact with other residents while the allegation was investigated. In an interview, the facility’s administrator told an inspector that the assistant “should have been removed from all resident contact” in addition to the resident in question.

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Bedford Center for Nursing and Rehabilitation received 36 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 22, 2019. It also received a Department of Health fine of $6,000, in September 2011, over alleged violations of sections of the health code relating to the investigation and reporting of allegations, accidents and supervision, and administrative practices. The Brooklyn nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The facility did not provide an adequate level of treatment and services to prevent and heal pressure ulcers. Section 483.25 of the Federal Code states that nursing homes must provide residents with “care, consistent with professional standards of practice, to prevent pressure ulcers.” A November 2018 citation found that Bedford Center for Nursing and Rehabilitation failed to ensure that a resident received adequate care to prevent pressure ulcers. An inspector specifically observed on multiple instances that the resident was in their bed without wearing heel booties. According to the citation, the resident was at “very high risk” for skin breakdown, and medical orders directed that heel booties be applied while the resident is in bed. In interviews, both a Registered Nurse and a Licensed Practical Nurse stated that they were not certain why the resident was not wearing the necessary assistive devices while in bed.

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North Westchester Restorative Therapy and Nursing Center received 14 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Mohegan Lake 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 residents a medication error rate below 5%. Under Section 483.45 of the Federal Code, nursing homes must maintain medication error rates that do not reach or exceed 5%. A January 2019 citation states that during a recertification survey, North Westchester Restorative Therapy and Nursing Center experienced a medication error rate of 6.45%, attributing this rate to two instances of medication errors. According to the citation, an inspector observed a Licensed Practical Nurse providing a resident with an inhaler and instructing her to “put the inhaler and her lips and take a deep breath in.” The nurse then provided the resident with another inhaler and gave the same instructions. The citation states that the manufacturer’s instructions for the inhalers in question state in part that users should: “before you inhale, breathe out (exhale) through your mouth and push out as much air from your lungs as you can. Hold your breath for about 10 seconds, or for as long as you can.” The nurse in question stated that she was unaware of this requirement, or that it was a standard practice “to wait approximately 10 minutes in between administration of 2 different inhalers.”

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Salem Hills Rehabilitation and Nursing Center received 14 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 26, 2019. The Purdys nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did ensure residents’ right to freedom from abuse. Under Section 483.12 of the Federal Code, nursing home facilities must uphold residents’ right to freedom “from abuse, neglect, misappropriation of resident property, and exploitation.” A March 2019 citation found that the nursing home did not ensure this right for one of three residents. An inspector specifically found that a Certified Nursing Assistant, in response to a resident slapping her face, “grabbed and held the resident’s left wrist while continuing to hold the right wrist firmly.” A plan of correction undertaken by the facility included, in part, educating CNAs so they “understand that holding on to another person’s hands or wrist as a knee jerk… action” is not appropriate, and that they should instead distance themselves from residents and seek assistance.

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Sans Souci Rehabilitation and Nursing Center received 15 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 29, 2019. The Yonkers 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 maintain sufficiently low medication error rates. Section 483.45 of the Federal Code states that nursing homes must maintain medication error rates that do not reach or exceed five percent. An August 2018 citation states that errors connected to two residents observed during a medication pass resulted in an error rate of 9.6%. An inspector specifically observed a nurse provide a resident with a multiple vitamin tablet instead of a multiple mineral tablet, and observed another nurse administer a resident with one off of an inhaler rather than two puffs, and administer that resident with an artificial tear solution with a strength that was not the same strength ordered by the physician. The citation states that these errors resulted in the “potential to cause more than minimal harm” to residents.

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The Enclave at Rye Rehabilitation and Nursing Center received 34 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 29, 2019. The Port Chester nursing home’s citations resulted from a total of four inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not thoroughly investigate an allegation of abuse. Section 483.12 of the Federal code states in part that nursing homes must provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated, and that the results of these investigations are reported to the proper authorities in a timely manner. An October 2018 citation found that The Enclave failed to properly investigate a resident’s allegation that she was sexually assaulted while sleeping. The citation states that there was “no documented evidence that the facility completed a thorough investigation of the resident’s allegation,” specifying further that there was no evidence the facility timely obtained interviews and statements from staffers who may have had knowledge of the events surrounding the alleged incident. Records show that in response to the citation, “the investigation was re-opened and reported to the Department of Health.”

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The Grove at Valhalla Rehabilitation and Nursing Center received 27 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on November 29, 2019. The Valhalla nursing home’s citations resulted from a total of four inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately implement an infection prevent and control system. Under Section 483.80 of the Federal Code, nursing home facilities must create and maintain infection prevention and control protocols that are “designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.” An August 2018 citation found that the facility did not properly ensure its staff undertook adequate hand hygiene measures “to prevent cross contamination and the spread of infection” in connection to one resident. The citation states specifically that during a wound observation of the resident, who was at risk of developing a pressure ulcer, an inspector observed a Licensed Practical Nurse “his bare hands to reposition the resident in bed, in addition to pulling the bedside curtain to maintain privacy.” Then, without sanitizing his hands, the nurse in question put on a pair of of gloves with which he opened a saline solution bottle, poured the solution on gauze pads, and cleaned the resident’s wound. According to the citation, the nurse continued wearing “the soiled gloves” as he went on to perform several other activities that included touching the wound. The citation states that this conduct had the “potential to cause more than minimal harm.”

2. The nursing home did not properly implement its abuse and neglect investigation and reporting policies. Section 483.12 of the Federal Code requires nursing homes to develop and implement policies and procedures that prohibit and prevent abuse and neglect, and that provide for the investigation of abuse and neglect allegations. A November 2018 citation found that the nursing home failed to thoroughly investigate a resident’s unwitnessed fall, and to timely report the incident to state authorities in order to rule out the possibility of abuse, neglect, or mistreatment. The citation states further that the nursing home failed to report and investigate a second fall sustained by the resident. In response to the citation, the nursing home initiated an investigation into one of the incidents, and stated its intention to report the incident and the investigation’s results to state health authorities.

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