Articles Posted in Pressure Sores

Rockville Skilled Nursing & Rehabilitation Center received 18 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 14, 2020. The Rockville Centre 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 treat and care for residents’ pressure ulcers and bedsores.  Section 483.25 of the Federal Code requires nursing homes ensure that residents with pressure ulcers receive “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure one resident with pressure ulcers received such. The citation states specifically that although a nurse noted the resident’s bilateral heels had “discoloration and were soft and tender,” the Registered Nurse’s full assessment of that resident’s heels “was not relayed to the physician in a timely manner, resulting in a delay in treatment.” In an interview, the Registered Nurse Supervisor stated that she had assessed the resident and documented her findings, but “forgot to write a progress note,” and then passed the findings to a wound nurse. In an interview, that nurse stated that she told the RN supervisor that a note had to be put in the resident’s medical record, and further that told the facility’s Assistant Director of Nursing Services about the resident’s condition, who “wanted to wait for the progress note to be written.”

2. The nursing home did not take adequate measures to prevent residents from being administered unnecessary psychotropic drugs. Section 483.45 of the Federal Code requires nursing homes to ensure 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.” A December 2017 citation found that Rockville Skilled Nursing & Rehabilitation Center did not ensure residents taking medication for a redacted condition received gradual dose reductions, “unless clinically contraindicated, in an effort to discontinue these drugs.” The citation specifically describes one resident who was prescribed an antipsychotic medication, Quetiapine, and whose psychiatrist and pharmacy consultant “both recommended a tapering of the medication.” However, according to the citation, “there was no documented evidence that the physician took any action” to implement this recommendation. A plan of correction undertaken by the facility included the implementation of the drug’s dose reduction.

Sands Point Center for Health and Rehabilitation received 35 citations for violations of public health code between 2016 and 2020, according to New York State Department of Health records accessed on March 15, 2020. The Port Washington 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 pressure ulcer care and treatment. Section 483.25 of the Federal Code stipulates that nursing homes must provide residents with pressure ulcers “necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.” A July 2018 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for one resident. The citation states specifically that “there was no documented evidence that a skin condition to the sacrum was assessed or received treatment until five days after the resident was admitted to the facility.” In an interview, the facility’s wound nurse stated that she had not seen the resident until several days after a note was left for her about the wound, and that “the wound should have been treated sooner.” The facility’s Medical Doctor stated further, in an interview, that “the doctor should have been called over the weekend and a treatment initiated.”

2. The nursing home did not take adequate measures to protect residents from the use of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes are required to keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Sands Point Center for Health and Rehabilitation did not ensure such for three residents. The citation goes on to state specifically that one resident was administered an antipsychotic medication despite an absence of any “documented justification or attempts at non-pharmacological intervention”; that another resident was administered an antipsychotic medication without an appropriate diagnosis and that a third resident was administered multiple drugs, including an antipsychotic, without an appropriate psychiatric diagnosis. The citation states that this deficiency had the “potential to cause more than minimal harm” to residents.