Articles Posted in Medication Errors

The Pines at Poughkeepsie Center for Nursing & Rehabilitation suffered 19 fatalities from Covid-19 as of July 12, 2020, state records report. The nursing home also received 12 citations over violations of public health code between 2016 and 2020, according to health records accessed on July 13, 2020.  One of those citations concerns findings that the facility’s infection control procedures were deficient. The Poughkeepsie nursing home’s citations resulted from a total of two surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not take adequate steps to prevent infection. Section 483.30 of the Federal Code stipulates that nursing homes must create and maintain a program designed to prevent and control infection and disease. A December 2018 citation found that Pines at Poughkeepsie Center for Nursing & Rehabilitation did not ensure such. The citation stats specifically that staff did not follow proper hand hygiene during a lunch meal observation, and further that staff did not perform proper gloving and hand hygiene during wound care treatment. During the meal observation, a staff member was observed picking up her badge from the floor after it fell and placing it back on her clothing, then reaching over and holding the resident’s arm and continuing to assist the resident with lunch meals and fluid, without first washing her hands. In the same meal observation, a Certified Nursing Assistant was observed removing the leg rests from a resident’s wheelchair, placing them on the floor, placing her hand on the resident’s arm, then leaving the resident, removing a lunch tray from a dining cart, delivering it to another resident, opening it, cutting the meat, and opening the milk container, all without being observed washing her hands. With respect to the wound observation, a Registered Nurse Manage was observed washing her hands, preparing a dressing field, donning gloves to remove the soiled dressing that had drainage on it, and cleansing the wound without removing the soiled gloves or washing her hands. A plan of correction undertaken by the facility included the in-servicing of relevant staff.

2. The nursing home did not maintain low enough medication error rates. Section 483.45 of the Federal Code requires nursing homes to ensure that “medication error rates are not 5 percent or greater.” A December 2018 citation found that The Pines at Poughkeepsie Center for Nursing & Rehabilitation did not ensure such. The citation states specifically that in one instance, a resident was incorrectly administered eyedrops; in another, a resident was not administered insulin at the proper time. A plan of correction undertaken by the facility included the in-servicing of relevant employees.

St. John’s Health Care Corporation suffered 20 fatalities from Covid-19 as of June 29, 2020, per state records. The nursing home also received 56 citations finding it violated public health code between 2016 and 2020, according to health records accessed on June 30, 2020, including two citations that dealt with infection control deficiencies. The facility has also received fines totaling $20,000 over findings that it violated health code provisions regarding quality of care. The Rochester nursing home’s citations resulted from a total of nine surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not take effective measures to prevent infection. Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain an infection prevention and control program that helps ensure a safe and sanitary environment for residents. A November 2017 citation found that St. John’s Health Care Corporation did not ensure such for one resident. The citation states specifically that after providing incontinence care for the resident, a Certified Nursing Assistant “removed the black booties and socks from the resident’s feet, then dumped out water” without first removing his gloves. The CNA was then observed applying a cream to the resident’s rectal area, then, without first removing his gloves or washing his hands, rolling the resident on his back and applying the cream to the resident’s perineal creases, applying Attends, pulling up the resident’s pants, applying socks and booties, and emptying the resident’s wash bin. In an interview, the CNA said that he should have changed his gloves and washed his hands at certain points during the provision of care.

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Cold Spring Hills Center for Nursing and Rehabilitation suffered 15 fatalities from Covid-19 as of June 29, 2020, per state records, though a New York Post report suggests that number is significantly undercounted. The nursing home also received 56 citations finding it violated public health code between 2016 and 2020, according to health records accessed on June 30, 2020; one such citation concerned infection control procedures. The facility has also received fines totaling $24,000 after findings that it violated health code provisions concerning quality of care, staff mistreatment of residents, and accidents. The Woodbury nursing home’s citations resulted from a total of 1 surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not maintain an adequate infection prevention and control program. Section 483.80 of the Federal Code stipulates that nursing homes must “establish and maintain an infection prevention and control program” in order to provide residents with a safe and sanitary environment. An October 2018 citation found that Cold Spring Hills Center for Nursing and Rehabilitation failed to ensure such. The citation states specifically that infection control protocols were broken during a resident’s pressure ulcer wound change: a Registered Nurse was observed cleansing the wound without changing her gloves and washing her hands in between certain procedures to prevent contamination. In two separate instances, an inspector also observed a resident with their Foley Catheter collection bag resting on the facility’s floor, in contravention of infection control protocols. A plan of correction undertaken by the facility included the counseling of relevant staff.

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Ross Center for Nursing and Rehabilitation received 31 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 9, 2020. The facility has also received a 2011 fine of $10,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding accidents and supervision. The Brentwood nursing home’s citations resulted from a total of five surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate bedsore / pressure ulcer treatment and care. Section 483.25 of the Federal Code requires nursing homes to ensure that residents with pressure ulcers are provided with treatment and services necessary “to promote healing, prevent infection and prevent new ulcers from developing.” A July 2017 citation found that Ross Center for Nursing and Rehabilitation did not ensure such for one resident. The citation states specifically that the nursing home “did not effectively evaluate factors that could be removed or modified to stabilize, reduce, or remove risk factors which contributed to the development and deterioration” of the resident’s pressure ulcer. According to the citation, the resident was given a concave mattress placed atop a pressure relieving mattress. In interviews, facility staff suggested that the concave mattress “impeded staff from properly turning and positioning” the resident, and further that the mattress “did not provide optimum level of pressure reduction for wound healing.” As such, according to the citation, the resident “developed a stage 2 pressure ulcer which then deteriorated to a stage 3.” A plan of correction undertaken by the facility included the educational counseling of its Unit Manager.

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St. Catherine of Siena Nursing and Rehabilitation Care Center received 12 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on April 11, 2020. The Smithtown nursing home’s citations resulted from a total of four surveys by state inspectors. The deficiencies they describe include the following:

1. 1. The nursing home did not implement adequate measures to mitigate medication errors. Section 483.45 of the Federal Code requires nursing homes to ensure that “residents are free of any significant medication errors.” A January 2019 citation found that St. Catherine of Siena Nursing and Rehabilitation Care Center did not ensure such for one resident. The citation states specifically that while the resident’s primary care physician had ordered the resident to receive an anticonvulsant medication twice a day, “the resident did not receive five consecutive doses of the prescribed anticonvulsant medication.” In interviews, facility staffers including the Registered Nurse Supervisor stated that they were not aware the medication in question had been unavailable on multiple days.

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Wingate at Beacon suffered 19 deaths from Covid-19 as of May 24, 2020, per state records. The nursing home also received 25 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on May 26, 2020. The facility has additionally received three enforcement actions: a 2016 fine of $2,000 in connection to findings in a 2010 inspection that it violated health code provisions regarding hydration; a 2016 fine of $10,000 in connection to findings in a 2012 inspection that it violated health code provisions regarding feeding via gastrostomy tubes and administrative matters; and a 2012 fine of $24,000 in connection to findings in a 2012 inspection that it violated health code provisions regarding accidents and supervision, food, services that meet professional standards, and administrative matters. The Beacon 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 have enough nursing staff. Section 483.35 of the Federal Code requires nursing homes to have “sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.” A September 2018 citation found that Wingate at Beacon did not ensure the availability of such. The citation states specifically that “multiple residents” stated in confidential interviews, as well as during a group meeting, that there were not enough Certified Nursing Aides “to respond to call bells and provide assistance during activities of daily living.” As a result, residents said, it sometimes took an hour to get a response after pressing a call bell; in some cases “showers were not done,” and in another, a resident required help getting off a toilet and waited more than 20 minutes. The citation goes on to state that nursing staff members reported a lack of adequate staffing in all units, and that an analysis of the facility’s staffing scheduled demonstrated that “on multiple occasions” it did not meet the required number of CNAs in all its units. A plan of care implemented by the facility included the identification of minimum staffing members.

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St. James Rehabilitation & Healthcare Center experienced 25 deaths from Covid-19 as of May 31, 2020, per state records. The nursing home also received 23 citations for violations of public health code between 2016 and 2020, according to health records accessed on June 1, 2020. The St. James nursing home’s citations resulted from a total of three surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not employ adequate measures to prevent infection. Section 483.80 of the Federal Code stipulates that nursing homes must create 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 May 2018 citation found that St. James Rehabilitation & Healthcare Center did not ensure such for one resident. The citation states specifically that the suction tubing tip connected to the resident’s suction machine was observed lying on the floor of their room, which had “multiple dried blackish stains.” In an interview, the facility’s Registered Nurse Charge Nurse said that the tubing “should not be touching the floor.” A plan of correction undertaken by the facility included the removal and discarding of the resident’s suction catheter.

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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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