Articles Posted in Medication Errors

Park Nursing Home received 39 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on January 3, 2020. The Rockaway Park nursing home’s citations resulted from a total of eight inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not ensure residents were protected from abuse. Under Section 483.12 of the Federal Code, nursing homes must ensure their residents “the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.” A February 2019 citation found Park Nursing Home did not ensure its residents remained free from abuse. The citation specifically found that “a cognitively impaired resident who displays physical aggression towards others physically assaulted more than one resident, one more than one occasion.” An inspector found that whereas the facility implemented interventions to address this resident’s conduct, these interventions “were not evaluated for their effectiveness.” A Director of Nursing stated in an interview that these interventions included separating the resident from others, close monitoring, and placing him with residents able to defend themselves; the DON said also that “these interventions were not all documented and should have been.”

2. The nursing home did not provide residents adequate supervision to prevent elopement. Section 483.25 of the Federal Code requires that nursing homes provide residents with “adequate supervision and assistance devices to prevent accidents.” An October 2018 citation found that Park Nursing Home did not adequately supervise a resident who had been “identified at risk for elopement” and who refused to wear a wander guard device. The citation goes on to state that the resident eloped the facility after climbing its back gate without staff knowledge; it notes specifically that the Registered Nursing Supervisor was not notified of the elopement until approximately three hours after it occurred, and the resident was returned after another two hours. The citation notes that the elopement was attributed in part to “a breach in security,” and the facility’s plan of correction included the termination of a security officer “who left his post.”

Concord Nursing and Rehabilitation Center received 44 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2016 fine of $14,000 in connection to findings it violated health code provisions regarding administration and respiratory care. The Brooklyn 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 supervision to

. Section 483.25 of the Federal Code requires nursing homes to provide residents with “adequate supervision and assistance devices to prevent accidents.” An August 2018 citation found that Concord Nursing and Rehabilitation Care did not adequately supervise residents who had been identified as at risk for elopement. The citation specifically found that a resident “was not provided with [a] wander guard” as per a physician’s order, and further that no documentation in the resident’s records indicated they were being supervised “to prevent unsafe wandering and/or elopement.” Although the resident had a physician order specifying for a wander guard on their left hand, according to the citation, when an inspector asked a Certified Nursing Assistant if the resident had one, none was found. The CNA stated in an interview that “the resident is confused and sometimes removes the wander guard,” and further that “there is no daily record monitoring the use of wander guard.”

Crown Heights Center for Nursing and Rehabilitation received 26 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2012 fine of $10,000 in connection to findings it violated health code provisions regarding quality of care care; and a 2011 fine of $10,000 in connection to findings it violated health code provisions regarding accidents and supervision, administration, professional services, and significant medication errors. 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 residents’ drug regimens were free of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes must keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Crown Heights Center for Nursing and Rehabilitation did not ensure a resident’s drug regimen was free of unnecessary drugs. The citation specifically found that the resident had been prescribed a certain medication absent a psychiatric evaluation, and “with no evidence of behaviors to support ongoing use” of the medication in question. The citation notes that the resident’s records contained no documentation indicating that they had been assessed by a psychiatrist or that the facility attempted a gradual dose reduction of the medication since the resident’s admission. A plan of correction undertaken by the facility included a psychiatric consult and an order to discontinue the medication.

2. The nursing home did not provide residents with adequate accident supervision. Section 483.25 of the Federal Code states that nursing homes must ensure residents receive adequate supervision and devices to prevent accidents. A March 2017 citation found that the nursing home did not provide each resident with adequate supervision and functioning equipment. The citation notes specifically that “a suction machine not being properly equipped for use in case of emergency” was observed in a dining room. An inspector observed the suction machine unplugged against the wall, with no tubing connected to it, and with no suction tip. When an inspector asked for a demonstration of the machine’s use, neither of two Licensed Practical Nurses were “able to attached [sic] the tubing to the machine,” with one leaving to retrieve correct tubing. The citation states that 15 minutes passed before the machine was properly ready for use, concluding that it “was not equipped for immediate use in the event of an emergency.”

King David Center for Nursing and Rehabilitation received 44 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The Brooklyn 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 ensure resident drug regimens were free from unnecessary drugs. Section 483.45 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs,” including drugs used in excessive duration and/or without adequate monitoring. An April 2019 citation found that King David Center for Nursing and Rehabilitation did not monitor a resident receiving anticoagulant therapy injections for symptoms and side effects of such. The citation notes specifically that the resident informed staff he had “bruising all along [the] lower quadrant of his stomach” and that he receives bruising whenever he receives the anticoagulant injections. The citation also states that notes kept by staff who administered the medication did not contain any documentation of the resident’s skin discoloration or bruising. In an interview, the resident’s MD stated that he would begin documenting the bruises, although he said they were not a cause for major concern.

2. The nursing home did not provide residents with a safe, clean, comfortable, and homelike environment. Section 483.10 of the Federal Code stipulates that nursing home residents have a right to a safe, clean, comfortable, and homelike environment. An April 2019 citation found that the nursing home did not ensure such, specifically observing that 6 resident rooms with “various signs of disrepair.” These signs included a room with cracked and broken wood along its entrance wall; rusted paint on an air conditioner cover; peeling and faded paint under a bathroom sink; faded paint on an air conditioner cover that was improperly affixed to the room’s wall; windows taped shut with duct tape; a fist-sized hole in a bathroom door; and a radiator that was not affixed to the wall. The citation states that these deficiencies had “potential to cause more than minimal harm.”

Buena Vida Continuing Care & Rehab Center received 23 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The Brooklyn 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 take adequate measures to prevent accidents. Section 483.25 of the Federal Code requires nursing home facilities to remain “as free of accident hazards as is possible” and to provide residents with adequate supervision and assistance to prevent accidents. An August 2019 citation found that Buena Vida Continuing Care & Rehab did not ensure one of its residents was free of accident and injury. The citation specifically found that the resident was served a dinner tray that included two cups of hot water. The resident was attempting to prepare tea when one of the cups spilled hot water onto her thighs, causing her to sustain an injury. The citation states that there was no documented instructions for facility staff regarding safe water temperatures when reheating water in the microwave, and that the incident resulted in “actual harm” to the resident.

2. The nursing home failed to ensure residents’ drug regimens were free from unnecessary medications. Section 483.45 of the Federal Code requires nursing homes to keep “each resident’s drug regimen… free from unnecessary drugs.” A May 2019 citation found that Buena Vida Continuing Care & Rehab used Valporic acid to treat a resident’s anxiety disorder and another unspecified condition “without ordering labs to monitor the Valporic acid levels” in the resident. The citation states that there was no evidence lab work was performed to test and monitor the acid levels, and notes that the facility’s Medical Director stated in an interview that “labs should have been done on the Valporic acid levels at least every 6 months even as a baseline.”

Bushwick Center for Rehabilitation and Health Care received 27 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The Brooklyn 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 follow food safety standards. Section 483.60 of the Federal Code requires nursing home facilities to “Store, prepare, distribute and serve food in accordance with professional standards for food service safety.” A January 2019 citation found that Bushwick Center for Rehabilitation and Health Care did not ensure the maintenance of cold food at proper temperatures. An inspector specifically found that tuna salad was stored at a temperature of 46 degrees Fahrenheit. The citation notes that facility policy and procedures governing food temperatures state that “potentially hazardous cold food items” such as tuna salad should be kept at an internal temperature at or below 41 degrees Fahrenheit. In an interview, one of the facility’s Dietary Aides stated that the temperature of the tuna salad was not taken prior to the preparation of sandwiches “since this is not a standard procedure to take the temperature of food items.” A plan of correction undertaken by the facility in response to the citation included the immediate disposal of the tuna salad and sandwiches that registered above 41 degrees.

2. The nursing home did not follow proper prevent and control infection practices. Under Section 483.80 of the Federal Code, nursing home facilities are required to “establish and maintain an infection prevention and control program” that fosters a “safe, sanitary and comfortable environment.” A January 2019 citation found that the nursing home did not maintain infection control practices in a manner adequate to prevent the development and transmission of diseases and infections. An inspector specifically observed a resident’s Foley Catheter drainage bag and tubing touching the floor and floor mats; and facility staff entering the room of a resident on contact precautions without wearing personal protective equipment. The citation states that these deficiencies had the “potential to cause more than minimal harm.”

Cobble Hill Health Center received 22 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The Brooklyn 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 maintain an environment free of accident hazards. Under Section 483.25 of the Federal Code, nursing homes are required to maintain an environment “as free of accident hazards as is possible” and to provide residents with supervision and assistance adequate to prevent them from sustaining accidents. A May 2019 citation found that Cobble Hill Health Center did not ensure the maintenance of an accident hazard-free environment, finding specifically that “eight (8) lighters were observed not locked or stored away leaving it accessible to others”; that the facility did not timely assess whether a resident who smokes required supervision; and that the resident’s smoking area did not provide for adequate supervision of a resident who smokes, and who was observed “putting out [a] lit cigarette on the ground in front of facility entrance and not in ashtray.” According to the citation, the resident was also observed “with a burn hole on his pants.” A plan of correction undertaken by the facility included the revision of facility policy to forbid residents from smoking inside or outside the nursing home.

2. The nursing home did not ensure residents’ right to be free from the unnecessary use of psychotropic medications. Section 483.45 of the Federal Code states in part that “Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record,” and that residents who do use them receive gradual dose reductions as well as behavioral indications to attempt to discontinue their use. A May 2019 citation found that the facility did not ensure a resident’s drug regimen was adequately monitored and managed “to promote or maintain the resident’s highest practicable mental, physical, and psychosocial well being.” The citation states specifically that the resident was prescribed Quetiapine, a psychoactive medication, without any “appropriate and clinical indication for use,” and without a documented assessment of the medication’s effectiveness, risks, and benefits. The citation states that this deficiency had the “potential to cause more than minimal harm.”

Palm Gardens Center for Nursing and Rehabilitation received 26 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 21, 2020. The Brooklyn 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 keep resident drug regimens free from unnecessary psychotropic drugs. Section 483.45 of the Federal Code stipulates that nursing homes must ensure resident drug regimen include no unnecessary medications that affect “brain activities associated with mental processes and behavior.” An April 2019 citation found that Palm Gardens Center for Nursing and Rehabilitation failed to ensure such in an instance in which a resident was prescribed a psychotropic medication without a clearly defined indication or use of non-pharmacological approaches. The citation goes on to state that interviews with facility nursing staff “did not substantiate the psychiatrist’s evaluation that the resident had behaviors or delusions that necessitated the use of an antipsychotic medication.” The facility states that this deficiency had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the discontinuation of the medication and the educational counseling of the psychiatrist assigned to the resident.

2. The nursing home did not ensure adequate respiratory care and services. Section 483.25 of the Federal Code stipulates that nursing home facilities must provide to respiratory care and services to residents who require such in a manner consistent with professional standards of practice. A June 2018 citation found that the facility failed to ensure such to two residents. The citation states that the nursing home did not “provide continuous mechanical ventilation on ventilator dependent residents,” specifically describing an incident in which two residents’ ventilators received an Operational Ventilation Procedure after which they were “found unresponsive and were pronounced dead at the facility within 10 minutes of each other.” An investigation found that after the procedure was conducted, the residents’ mechanical ventilation “was not resumed.” As such, one resident had no ventilation for an hour and 20 minutes, while the other resident had no ventilation for two hours and 14 minutes. The citation describes this deficiency as having “Immediate jeopardy to resident health or safety.”

The Riverside received 69 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 31, 2020. The Manhattan 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 implement adequate measures to prevent residents from sustaining accidents. Section 483.25 of the Federal Code provides for nursing homes to ensure residents an environment as free as possible from accident hazards, with adequate supervision to prevent accidents. A May 2019 citation found that The Riverside did not ensure adequate supervision to prevent accidents. The citation states specifically that a resident who had been identified as at risk for falls “was left unsupervised on multiple occasions,” and that another resident “was not monitored every 30 minutes after a fall as per the plan of care.” A plan of correction undertaken by the facility included the re-evaluation of the first resident, who “had no further falls,” and the in-servicing of nursing staff on the second resident’s plan of care.

2. The nursing home did not keep medication error rates adequately low. Under Section 483.45 of the Federal Code, nursing homes must maintain medication error rates that do not reach or exceed five percent. A May 2019 citation found that The Riverside’s medication error rates exceeded five percent. The citation specifically described “3 errors out of a total of 38 opportunities observed, resulting in a medication error of 7.89%.” The errors in question were connected to two residents who were administered medication outside of the allowed time. A plan of correction undertaken by the facility included re-education of the nursing staffer who administered the medication in those instances.

Upper East Side Nursing and Rehabilitation Center received 17 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 31, 2020. The facility has also been the subject of a 2018 fine of $12,000 in connection to findings during a February 2018 inspection that it violated unspecified health code provisions. The Manhattan 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 implement infection prevention and control policies and procedures. Section 483.80 of the Federal Code requires nursing homes to “establish and maintain an infection prevention and control program” that ensures residents a safe and sanitary environment. A March 2019 citation found that Upper East Side Nursing and Rehabilitation Center did not adequately maintain its infection control practices in such a manner as to prevent communicable diseases from arising and transmitting. A inspector specifically found that a resident’s “Catheter drainage bag and tubing were… touching the floor and the floor mat in the resident’s room.” The citation states that the inspector observed such on two separate instances, and that this deficiency contravened facility policy regarding indwelling catheters. A plan of correction undertaken by the facility included the re-education of relevant staff and an “observation audit to ensure the appropriate positioning of Foley bags.”

2. The nursing home did not maintain sufficiently low medication error rates. Section 483.45 of the Federal Code requires nursing homes to maintain medication error rates below five percent. A February 2018 citation found that Upper East Side Nursing and Rehabilitation Center did not ensure one of its residents was kept free of significant medication errors. The citation specifically describes a resident whose Primary Medical Doctor provided a telephone order for a certain medication. The resident was instead administered a different medication, according to the citation, and “found unresponsive approximately six hours later.” The citation notes that this deficiency resulted in “actual harm” to the resident.

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