Articles Posted in Medication Errors

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Buffalo Community Healthcare Center has received four fines and over 80 citations in the last four years for failing to prevent accidents from occurring, for lacking proper care for pressure ulcers, and for failing to avert any medication errors.

Buffalo Community Healthcare Center has received 82 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on October 1, 2021. The facility has also received four fines totaling $26,000 since 2017. The Buffalo nursing home’s citations resulted from a total of 10 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not take adequate steps to care for pressure ulcers. Section 483.25 of the Federal Code requires nursing homes to provide a consistent, professional level of care to prevent residents from developing avoidable pressure ulcers and to promote the healing of existing pressure ulcers. An April 2021 citation found that Buffalo Community Healthcare Center failed to ensure such. The citation states specifically that the nursing facility did not provide consistent weekly pressure ulcer assessments by a qualified person for one resident, and did not accurately document Treatment Administration Records. In an interview, a Registered Nurse said that the because the resident’s pressure ulcers were not treated as ordered or documented properly, the resident’s wounds “had the potential to get worse and because of the drainage, the wounds could get infected.” A plan of correction undertaken by the facility included the education of nursing staff.

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The Ellicott Center for Rehabilitation and Nursing has received over 70 citations in the last four years for failing to arrange proper accident prevention among patients, lacking sufficient care for pressure ulcers, and for failing to avert any medication errors.

Ellicott Center for Rehabilitation and Nursing has received 72 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on October 1, 2021. The facility has also received five fines totaling $40,000 since 2011. The Buffalo nursing home’s citations resulted from a total of 13 inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not provide adequate accident-prevention measures. Section 483.25 of the Federal Code requires nursing homes to ensure residents an accident-free environment. A February 2020 citation found that Ellicott Center for Rehabilitation and Nursing failed to ensure such. The citation specifically describes an instance in which the facility failed to ensure a shower chair lift fit through a shower room doorway. As a result, a resident “sustained a leg laceration, was transferred to the hospital and required 18 sutures.” In a separate incident, a resident was transferred without the use of a mechanical lift or safety devices as planned, and consequently suffered “actual harm” A plan of correction undertaken by the facility included the counseling of nursing staff.

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The New York State Department of Health has issued 63 citations to Delmar Center for Rehabilitation and Nursing for being in violation of protecting its patients from pressure ulcers, medication errors and failing to administer medicine at the correct times, and the use of unnecessary drugs.

Delmar Center for Rehabilitation and Nursing has received 63 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 25, 2021. The Delmar nursing home’s citations resulted from a total of eight inspections by state surveyors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent medication errors. Nursing home residents have the right to freedom from significant medication errors under Section 483.45 of the Federal Code. A February 2021 citation found that Delmar Center for Rehabilitation and Nursing failed to ensure such. The citation specifically states that it failed to ensure a resident’s medication orders “had not expired prior to administration.” It also described four residents whose medications were not received in a timely manner, in which cases the facility’s physician was not made aware the administrations were issued late. A plan of correction undertaken by the facility included the education of nursing staff.

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New York nursing home, The Grand Rehabilitation and Nursing at Barnwell, has been in violation of public health codes 66 times in the last four years and has been cited for medication failures, failure to prevent accidents and falls, and for neglect which has lead to incontinence and pressure ulcers.

The Grand Rehabilitation and Nursing at Barnwell received 66 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 17, 2021. It has also received eight fines totaling $78,000 since 2012. The Valatie nursing home’s citations resulted from a total of 17 surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not adequately protect residents from neglect. Section 483.12 of the Federal Code ensures nursing home residents the right to be free from neglect. A December 2018 citation found that The Grand Rehabilitation and Nursing at Barnwell failed to ensure such. The citation specifically describes the nursing home’s failure to timely provide one resident with interventions for skin, incontinence, and pressure ulcer care; to timely provide another resident with planned interventions with skin and bladder incontinence care; and to timely provide a third resident with planned interventions for pressure ulcer development and incontinence. According to the citation, the facility left the first resident uncared for for a period of 6 hours and 10 minutes, the second resident uncared for for a period of 11 hours and 37 minutes, and the third resident uncared for for a period of 11 hours and 51 minutes. A plan of correction undertaken by the facility included the educational counseling of nurses and nursing aides.

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Recent reports show that nursing homes are prescribing antipsychotic drugs at an alarmingly high rate to patients that do not even require these medications.

Nursing homes are over-diagnosing patients with schizophrenia in order to conceal the high rates at which they’re prescribing antipsychotic medications, according to a recent report by the New York Times. Schizophrenia diagnoses among nursing home residents have “soared” as much as 70% since the federal government started making public disclosures of antipsychotic drug prescriptions in 2012. These prescriptions factor into nursing homes’ funding and ratings: nursing homes that prescribe them at high rates can receive lower ratings from the government, which in turn can affect their funding.

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Linden Center For Nursing and Rehabilitation located in Brooklyn, NY has received multiple citations for being in violation of public health code and failing to protect their residents from infection and unnecessary medication.

Linden Center for Nursing and Rehabilitation received 16 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 3, 2021. The Brooklyn 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 failed to adequately protect residents from infection. Under Section 483.80 of the Federal Code, nursing homes are required to create and maintain a program to prevent and control the development and transmission of disease. A January 2019 citation found that Linden Center for Nursing and Rehabilitation failed to ensure such. The citation states specifically that the facility did not clean or adequately maintain certain areas in its laundry room. State inspectors observed “laundry bins in disrepair,” walls that were “chipped, dirty, in need of painting,” a dirty and clogged water drain, a floor in need of cleaning and sweeping, milk crates filled with dirty used mops, used employee coats and hats in the clean linen area, and overflowing garbage bins. In an interview, the facility’s Director of Housekeeping said that the facility had one housekeeper assigned to the area. A plan of correction undertaken by the facility included the education of laundry and housekeeping staffers.

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Rebekah Rehab and Extended Care Center has failed to protect residents from being given unnecessary psychotropic drugs.

Rebekah Rehab and Extended Care Center received 10 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on September 3, 2021. The Bronx 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 implement adequate measures to control infection. Section 483.30 of the Federal Code stipulates that nursing homes must create and maintain an infection prevention and control program to prevent the development and spread of viruses and disease. An August 2017 citation found that Rebekah Rehab and Extended Care Center failed to ensure such. The citation specifically describes a Licensed Practical Nurse who “did not remove gloves, perform hand hygiene and don’t clean gloves” after cleansing a resident’s pressure ulcer. In an interview after the procedure, the nurse stated, “I thought I was washing my hands as needed in regard to washing my hands and changing my gloves.” A plan of correction undertaken by the facility included the re-education of the staffer and the observation of other nursing staffers “to ensure that they were following appropriate wound care techniques.”

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A nursing home in Gowanda, New York has received citations for violations of health and safety code.

Gowanda Rehabilitation & Nursing Center received 28 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on August 14, 2021. The Long Beach nursing home’s citations resulted from a total of six surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with professional levels of care to promote the healing and prevent the infection of pressure ulcers. A May 2019 citation found that Gowanda Rehabilitation & Nursing Center failed to ensure such for two residents. The citation states specifically that there was no “weekly assessment by a qualified person after a pressure area was identified” for one resident, and that for the other there was “a five-day delay in assessment  by a qualified person” following the identification of a pressure area. A plan of correction undertaken by the facility included a full-house audit, the revision of the facility’s skin care protocol, and the educational counseling of nursing staff who did not properly document a resident’s pressure area.

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A nursing home in Long Beach, New York has received numerous citations in the last four years.

Park Avenue Extended Care Facility received 14 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on August 14, 2021. The Long Beach nursing home’s citations resulted from a total of four surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not properly prevent medication errors. Under Section 483.45 of the Federal Code, nursing home residents have the right to be “free of any significant medication errors.” A February 2020 citation found that Park Avenue Extended Care Facility failed to ensure such. The citation states specifically that the nursing home did not ensure one resident’s medication was administered in the parameters ordered by the physician. In an interview, a Licensed Practical Nurse said she had followed the instructions on the medication’s blister pack, and was not aware they reflected old physician’s orders that did not reflect current orders. In an interview, the facility’s Director of Nursing Services said that “the old blister pack should have been returned to the pharmacy by any one of the nurses on duty and replaced with the newly ordered medication blister pack.” A plan of correction undertaken by the facility included the educational counseling of the nurse in question.

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A nursing home in Troy, New York has received 45 health and safety code citations in the last four years.

Troy Center for Rehabilitation and Nursing received 45 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on August 14, 2021. The Troy nursing home’s citations resulted from a total of six surveys by state inspectors. The violations 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 ensure residents receive a level of supervision and assistance devices adequate to prevent them from sustaining accidents. A March 2021 citation found that Troy Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that the nursing home did not adequately supervise a resident with a history of wandering, who was subsequently found in another resident’s room. In an interview, one of the facility’s nurses said that the resident “was allowed to wander out of his room, and that there were no care planned interventions for supervising or monitoring” him. A plan of correction undertaken by the facility included the development of a care plan for wandering.

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