Articles Posted in Medication Errors

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A recent report by the Long Term Care Community Coalition shares that deficiencies in nursing homes across the United States are not being classified as harmful to the residents, which appears to be false and potentially dangerous for many nursing home residents.

A recent report by the Long Term Care Community Coalition raises important questions about “no harm” deficiencies in nursing homes across the United States.  “No Harm” deficiencies are health violations cited by official surveyors that are classified as causing no harm to residents. As the LTCCC argues in its Elder Justice newsletter, “no harm” citations often appear on their face to indeed be harmful, and that because they rarely result in financial penalties, this potentially erroneous classification leaves nursing homes without any incentive to correct systemic deficiencies. The LTCCC report describes several recent “no harm citations,” asking the reader whether the classification appears honest and accurate.  Continue reading

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Fulton Commons Care Center has received 12 citations for being in violation of public health code since 2018 after a total of 6 surveys by state inspectors lead to the discovery of multiple deficiencies within the East Meadows nursing home.

Fulton Commons Care Center received 12 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 15, 2022. The East Meadows 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 adequately protect residents from abuse. Section 483.12 of the Federal Code provides nursing home residents the right to freedom from abuse. A January 2022 citation found that Fulton Commons Care Center failed to ensure such. The citation specifically states that after one resident reported that a licensed practical nurse “inappropriately touched” them, the LPN continued working at the facility. Less than two weeks after the resident reported that alleged incident, another resident reported that the same LPN “exposed their genitals” to them. Both residents, according to the citation, had “intact cognition,” and both “reported being afraid and not feeling safe.” The citation states that the nursing home “failed to notify law enforcements and the New York State Department of Health within 2 hours.” A plan of correction undertaken by the facility included the suspension and subsequent termination of the LPN, as well as the termination of the nursing supervisor “who failed to timely report” the first alleged incident.

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Central Island Healthcare has received 29 citations for being in violation of public health code since 2018 after a total of four surveys by state inspectors found deficiencies within the facility.

Central Island Healthcare received 29 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 15, 2022. The Plainview 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 protect residents from the unnecessary use of psychotropic medications. Section 483.45 of the Federal Code stipulates that nursing homes who have not used psychotropic medications should not be given them unless medically necessary. An August 2019 citation found that Central Island Healthcare failed to ensure such. The citation specifically describes a resident who was started on an unspecified antipsychotic medication “without any documented evidence of the clinical need for the medication.” The citation goes on to state that the medication’s administration frequency was increased from once a day to twice at day at the request of the resident’s family, and that the dosage was doubled “due to a medication error entry.” A plan of correction undertaken by the facility included the resident’s examination by a physician and a psychiatrist, after which the resident’s medication dosage was adjusted.

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Sapphire Nursing and Rehab at Goshen has received 19 citations for being in violation of public health code since 2018 after multiple deficiencies were found during a total of 4 surveys by state inspectors.

Sapphire Nursing and Rehab at Goshen received 19 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Goshen 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 protect residents from the unnecessary use of psychotropic medications. Under Section 483.25 of the Federal Code, nursing homes must ensure resident drug regimens are free of unnecessary drugs, including psychotropic drugs. A December 2019 citation found that Sapphire Nursing and Rehab at Goshen failed to ensure such. The citation states specifically that there was a lack of documentation indicating the continued use of an antipsychotic drug by one resident. In an interview, the facility’s Registered Nurse Manager stated that the resident “did not have behavior issues” and that “non-pharmacalogical interventions had not been implemented prior to the start” of the anti-psychotic drug regimen. A plan of correction undertaken by the facility included the review of the resident’s medical record and the implementation of a gradual dose reduction.

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Glen Arden received 15 citations for being in violation of public health code between 2018 and 2022 after a total of 3 surveys by state inspectors found multiple deficiencies within the nursing home.

Glen Arden received 15 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Goshen 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 provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes must provide residents with a level of care necessary to promote the healing of pressure ulcers. A September 2020 citation found that Glen Arden failed to ensure such. The citation specifically states that a nurse practitioner’s recommendations to promote the healing of a “new deep tissue injury” and scab on a resident’s toe “were not implemented timely.” In an interview, the nurse practitioner said that this lapse could potentially result in an infection. A plan of correction undertaken by the facility included the updating of the resident’s care plan and treatment of the resident’s wound. 

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The Willlows at Ramapo Rehabilitation and Nursing Center has received 23 citations for being in violation of public health code since 2018 after a total of 4 surveys by state inspectors found multiple deficiencies within the facility.

The Willows at Ramapo Rehabilitation and Nursing Center received 23 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 7, 2022. The Haverstraw 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 provide adequate supervision to prevent elopement. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with a level of supervision necessary to prevent accidents. A September 2021 citation found that The Willows at Ramapo failed to ensure such. The citation specifically describes an incident in which the facility’s receptionist “left the front desk without coverage, leaving the front desk unattended,” after which a resident with severe cognitive impairment “was able to exit the facility undetected by staff.” The resident was later discovered in the parking lot by facility staff. A plan of correction undertaken by the facility included an audit of residents at risk of elopement to ensure the proper placement and functioning of their wander guard devices.

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Isabella Geriatric Center has received 21 citations for being in violation of public health code between 2018 and 2022 after a total of 5 surveys by state inspectors had lead to the discovery of multiple deficiencies within the Manhattan nursing home.

Isabella Geriatric Center has received 21 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on April 1, 2022. The Manhattan nursing home’s citations resulted from a total of 5 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 stipulates that nursing homes must provide residents with adequate supervision to prevent accidents. A July 2021 citation found that Isabela Geriatric Center failed to ensure such. The citation specifically describes an instance in which a resident being escorted to an outside appointment was not secured in their chair with a safety belt. As a result, the citation states, the resident slid from their chair to the floor of an ambulette, sustaining “bilateral fractures of the lower extremities.” A plan of correction undertaken by the facility included the re-education of relevant staff.

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Rutland Nursing Home has received 35 citations for being in violation of public health code since 2018 after state inspectors performed a total of five surveys and found deficiencies within the Brooklyn nursing home.

Rutland Nursing Home has received 35 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on March 25, 2022. 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 adequately protect residents from the use of unnecessary anti-psychotic medications. Under Section 483.45 of the Federal Code, nursing homes are required to keep residents’ drug regimens free from the unnecessary medications, including psychotropic drugs unless medically necessary. An August 2021 citation found that Rutland Nursing Home failed to ensure such. The citation specifically describes a resident who was administered a psychotropic medication despite the absence of “specific documentation of specific behaviors” that would merit such. In an interview, a registered nurse said that “they cannot say if this medication is needed for this resident.” The citation states further that the RN “was also unable to describe what behaviors the resident presented when considered agitated.” A plan of correction undertaken by the facility included the discontinuation of the medication.

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The New Jewish Home has received 39 citations for being in violation of public health code since 2018 after a total of 10 surveys were performed by state inspectors and lead to the discovery of multiple deficiencies.

The New Jewish Home has received 39 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on March 25, 2022. The Manhattan nursing home’s citations resulted from a total of 10 surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately 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 December 2021 citation found that The New Jewish Home failed to ensure such. The citation specifically describes in which a resident was given an incorrect dosage of a redacted medication. In an interview, the registered nurse who administered the medication said, “To tell you the truth, I was not looking at the percentage and I did not read the instructions that after opening it has to be refrigerated and to use only within 96 hours.” A plan of correction undertaken by the facility included the re-education of the nurse in question. 

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Williamsbridge Center for Rehabilitation and Nursing has received a total of 24 citations for being in violation of public health code since 2018 after state inspectors found multiple deficiencies within the nursing home.

Williamsbridge Center for Rehabilitation and Nursing has received 24 citations for violations of public health code between 2018 and 2021, according to New York State Department of Health records accessed on February 18, 2022. The Bronx 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 infection-prevention measures. Under Section 483.80 of the Federal Code, nursing homes must create and maintain a program to prevent and control the development and transmission of disease. A May 2021 citation found that Williamsbridge Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically the facility’s contracted vendors did not wear proper personal protective equipment while in the room of a resident on contact and droplet precautions. The citation goes on to describe an instance in which a resident’s “indwelling catheter drainage bag was on the floor on multiple occasions.” A plan of correction undertaken by the facility included the education of the  vendors in question on hand-washing and PPE procedures, as well as the in-servicing of nursing staff on the positioning of drainage bags. 

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