Articles Posted in Medication Errors

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The nursing home has been cited for medication errors and accident hazards, among other health code violations.

Elderwood at Hamburg suffered 26 confirmed COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Hamburg 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 measures to prevent and control 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 September 2020 citation found that Elderwood at Hamburg failed to ensure such. The citation states specifically  that the facility failed to maintain a program “to ensure the health and safety of residents to help prevent the transmission of COVID-19.” It goes on to state that the nursing home failed to maintain social distancing on two resident care units. A surveyor observed residents “sitting side by side in wheelchairs less than 6 feet apart across from the Unit 2 Nurses Station,” with face masks hanging on the back of their wheelchairs. When a Registered Nurse walked past the residents, the citation states, she “made no attempt to socially distance the residents six feet apart.” A plan of correction undertaken by the facility included Covid-19 testing for the residents in question, who were found to be negative.

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The New York nursing home received 36 health citations in the last four years.

Newfane Rehab & Health Care Center suffered 21 confirmed and 7 suspected COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 36 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Newfane 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 adequately protect residents from accidents. Under Section 483.25 of the Federal Code, nursing homes must provide every resident with “adequate supervision and assistance devices to prevent accidents.” A September 2019 citation found that Newfane Rehab & Health Care Center failed to ensure such. The citation states specifically that a resident who was care-planned to receive check-ups every 15 minutes and one-to-one supervision when off-unit was “observed wandering off the unit with no 1:1 staff or 15-minute check.” A plan of correction undertaken by the facility included the updating of the resident’s care plan and a monthly review of weekly wander-guard system summaries.

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As of January 17, 2021, the New York nursing home had 22 confirmed COVID-19 deaths.

Our Lady of Peace Nursing Care Residence suffered 22 confirmed COVID-19 deaths as of January 17, 2021, according to state records. The facility has also received 13 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on January 17, 2020. The Lewiston 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 protect residents from accidents. Section 483.25 of the Federal Code requires nursing homes to provide residents with sufficient supervision and assistive devices to prevent them from sustaining accidents. A January 2020 citation found that Our Lady of Peace Nursing Care Residence failed to ensure such for one resident. The citation states specifically that the resident was on aspiration precautions and that their care plan provided for “small bites and sips, alternate solids with liquids, encourage to eat slow, supervision assistance with eating.” However, the citation states, the resident was not adequately supervised during a mealtime and “was observed to cough several times.” A plan of correction undertaken by the facility included a review of aspiration precaution procedures and the re-education of nurses involved with the resident’s feeding assistance.

A new analysis by City and State asks whether New York’s nursing home facilities are prepared for another wave of the Covid-19 pandemic. Noting that while long-term care facilities have so far accounted for about 8% of Covid-19 cases, they have comprised about 40% of US fatalities from the disease. In New York especially, there have been 27,307 total Covid-19 deaths, of which 6,967 confirmed or presumed Covid-19 fatalities took place in nursing home facilities, a number that excludes residents who died outside of the facility. While nursing homes have improved their policies and procedures when it comes to Covid-19 since the virus initially struck, City and State argues, “there are still vulnerabilities that could leave nursing-home residents and staff at risk again.”

On the positive side, nursing homes are more likely to have more consistent access to tests and personal protective equipment, the analysis suggests. Nursing homes have already been conducting regular testing of all employees, and are required to have a 60-day supply of PPE. Additionally, a state rule has been reversed that in the spring led to nursing homes accepting Covid-19 patients from hospitals, spreading the virus throughout facilities.

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Bensonhurst Center for Rehabilitation and Healthcare suffered 10 confirmed Covid-19 deaths and 27 presumed Covid-19 deaths as of November 23, 2020, according to state records. The nursing home received 25 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on November 23, 2020. 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 sanitary food services. Section 483.60 of the Federal Code requires nursing homes to “procure food from sources approved or considered satisfactory by federal, state or local authorities” and ensure food is stored in compliance with professional standards of practice. A February 2020 citation found that Bensonhurst Center for Rehabilitation and Healthcare failed to ensure such. The citation states specifically that the facility did not ensure its food service workers performed hand hygiene before they handled food. An inspector also observed a meat slicer that “was not properly cleaned after use.” The citation goes on to state that despite the nursing home’s policies stating “gloves must be changed or removed before starting another job and Don’t forget always wash hands when you change gloves before starting another job,” a dietary aide “was observed touching the trash can lid without gloves as he discarded empty metal pudding cans,” then donning cleaning gloves, cleaning the tilt skillet, removing his gloves, and discarding leftover food without washing his hands first. The Aide was observed handling various other items and scooping cereal into a paper cup without first washing his hands. A second dietary aide was observed cleaning the meat slicer without removing its sharpener blade, on which meat debris was observed after the cleaning. A plan of correction undertaken by the facility included the in-servicing of kitchen staff. Continue reading

Huntington Living Center has received 38 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 28, 2020. The Waterloo 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 take adequate measures to prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must create a resident environment as free as possible from accident hazards, and with adequate supervision to prevent accidents. A February 2020 citation found that Huntington Living Center did not ensure such. The citation states specifically that a resident smoked in an area that was not designated for smoking, and the resident was further storing their own lighter. The citation goes on to state that the resident’s smoking supplies were supposed to be stored in the nurse’s unit, and that the resident was supposed to smoke off-property at the far side of a parking lot. In an interview, the resident stated that “they were supposed to smoke over on the next street by the church, but it was further away,” and that “they try to remember to lock the lighters up but they do not always remember to do that.” A plan of correction undertaken by the facility included a review of the facility’s smoking policies and protocols.

2. The nursing home did not adequately prevent infection. Under Section 483.80 of the Federal Code, nursing home facilities are supposed to endeavor to prevent and control infections via an infection control program. A February 2020 citation found that Huntington Living Center did not ensure such. The citation states specifically that the nursing home’s employees “did not follow appropriate infection control techniques or hand hygiene” for three residents reviewed for blood glucose testing and wound infections. It goes on to state that a blood sugar monitoring device was not properly cleaned after three resident uses, and that appropriate hand hygiene was not followed for another resident. A plan of correction undertaken by the facility included the re-education of relevant staff.

Steuben Center for Rehabilitation and Healthcare has received 38 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received a 2018 fine of $10,000 in connection to findings in a 2017 inspection that it violated unspecified health code provisions. The Bath 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 protect residents from abuse. Section 483.12 of the Federal Code grants nursing home residents “the right to be free from abuse.” A January 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for one resident. The citation states specifically that a Licensed Practical Nurse was witnessed undressing and washing the resident after the resident told the LPN to stop, then pushing the resident onto the toilet when the resident attempted to stand up. The citation also states that the LPN told another nurse at the facility “that she wanted to use the biggest needle she could find on the resident.” A plan of correction undertaken by the facility included the suspension and subsequent termination of the LPN.

2. The nursing home did not properly prevent infection. Section 483.80 of the Federal Code stipulates that nursing homes must maintain a program to prevent and control infection. A July 2018 citation found that Steuben Center for Rehabilitation and Healthcare did not ensure such for two residents. The citation states specifically that a nurse “did not properly disinfect the blood glucose testing machine (glucometer) before or after resident use.” In an interview, the nurse said “she should have wiped the glucometer down between residents” and that “she usually cleans the glucometer with bleach wipes that are located at the nurses’ station.” The facility’s Assistant Director of Nursing said in another interview that “she would expect the nurse to clean the glucometer in between residents using the approved bleach wipes.”

Oak Hill Rehabilitation and Nursing Care Center has received 22 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The Ithaca 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 significant medication errors. Under Section 483.25 of the Federal Code, nursing homes must ensure residents “are free of any significant medication errors.” A February 2020 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for three medications. The citation states specifically that the residents “did not receive significant medications as ordered.” A plan of correction undertaken by the facility included the administration to two residents of their missed doses, and an RN Assessment of all three residents, one of whom was already discharged.

2. The nursing home did not properly prevent and control infection. Section 483.80 of the Federal Code requires nursing homes to create and maintain a program designed to ensure residents a safe and sanitary environment via the maintenance and control of infection. A February 2019 citation found that Oak Hill Rehabilitation and Nursing Care Center did not ensure such for one resident. The citation states specifically that the resident’s catheter bag and tubing were resting directly on the facility’s floor, in violation of health policy. It goes on to state that the facility’s washers and dryers “were not maintained according to user manual,” and that “There was no documented facility policy for the maintenance of the washers and dryers.” A plan of correction undertaken by the facility included the placement of the resident’s catheter in a labeled basin, and the required maintenance of the washers and dryers.

Kendal at Ithaca has received 16 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The Ithaca 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 prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must ensure resident environments are “as free of accident hazards as is possible.” A July 2016 citation found that Kendal at Ithaca did not ensure such. The citation states specifically that the facility’s hot water was too hot. It goes on to describe “the hot water temperature [that] was determined to be over 120 degrees Fahrenheit.” It states further that a Hot Water Return Status form “did not document any action taken after the hot water that was found to be too hot,” and “no documented evidence elsewhere that any action was taken to reduce the hot water temperature after it was determined to be too hot.” A plan of correction undertaken by the facility included adjustments to the mixing valves in the affected units.

2. The nursing home did not adequately comply with food safety standards. Under Section 483.35 of the Federal Code, nursing homes must store and prepare food under sanitary conditions. A July 2016 citation found that Kendal at Ithaca did not ensure such in two of its four kitchens. The citation states specifically that “spoiled and outdated foods were stored in the cafeteria walk-in refrigerator” and that an employee tested the sink’s sanitizer concentration using “an unapproved method.” The citation states that these deficiencies had the “potential to cause more than minimal harm.” A plan of correction undertaken by the facility included the discarding of spoiled and outdating food and the re-education of the employee in question.

Groton Community Health Care Center Residential Care Facility has received 96 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on August 19, 2020. The facility has also received fines totaling $20,000 in connection to findings that it violated health code provisions regarding equipment conditions, pressure sore care, accidents, and administrative practices. The Groton 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 comply with infection control practices and procedures. Section 483.80 of the Federal Code requires nursing homes to “establish 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 January 2019 citation found that Groton Community Health Care Center Residential Care Facility did not ensure such. The citation states specifically that facility staff did not perform hand hygiene while changing a resident’s wound pressure ulcer wound dressing. The citation goes on to describe a Licensed Practical Nurse who, while treating the resident’s wound, “removed her soiled gloves after removing the old dressing, then immediately donned another pair of gloves without performing hand hygiene.” In an interview, the nurse said “she should have performed hand hygiene between glove changes.” In another interview, the facility’s infection control nurse said that “she expected staff to perform hand hygiene after removing and before replacing gloves when completing a dressing change.”

2. The nursing home did not adequately prevent medication errors. Under Section 483.45 of the Federal Code, nursing homes must keep residents “free of any significant medication errors.” A May 2018 citation found that Groton Community Health Care Center Residential Care Facility failed to ensure such for one resident. It goes on to describe specifically a resident who “was not consistently provided with her heart medication as ordered and the facility did not identify the root cause to prevent reoccurrence.” A plan of correction undertaken by the facility included the review and revision of the facility’s medication error policy and the provision of a monthly review of medication error’s to the facility’s QAA committee and Medical Director.

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