Collar City Nursing and Rehabilitation Center: Medication Error Citation

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Collar City Nursing and Rehabilitation Center received 65 citations for being in violation of public health code between 2018 and 2022 after a total of 10 inspections by state surveyors and their findings.

Collar City Nursing and Rehabilitation Center received 65 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on June 10, 2022. The Troy nursing home’s citations resulted from a total of 10 inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not keep medication error rates low enough. Under Section 483.25 of the Federal Code, nursing homes must ensure “medication error rates are not 5 percent or greater.” An April 2021 citation found that Collar City Nursing and Rehabilitation Center failed to ensure such. The citation states specifically that in one medication pass observed by state surveyors, there was a medication error rate of 9.68%. Among other things, the errors included a misapplication of artificial tear drops and the administering of medication to a resident whose systolic blood pressure was higher than the level at which staff were ordered to hold the medication. A plan of correction undertaken by the facility included the re-education of the Licensed Practical Nurse found responsible for the errors.

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The nursing home was cited for failing to prevent medication errors and keep the error rate below 5%, they did not properly prevent accidents from occurring within the facility, and the nursing home did not implement measures to prevent infection.

2. The nursing home did not adequately prevent accidents. Under Section 483.25 of the Federal Code, nursing homes must provide residents with “adequate supervision and assistance devices to prevent accidents.” A September 2020 citation found that Collar City Nursing and Rehabilitation Center failed to ensure such. The citation specifically describes an instance in which a resident with “severe cognitive impairment” was not adequately supervised “to prevent an inappropriate physical interaction” with another, moderately impaired resident. The citation states further that the former resident was later found in the latter resident’s room “in a compromised position” and “engaging in a sexual act.” A plan of correction undertaken by the facility included the placement of the former resident “on behavior monitoring.” 

3. The nursing home did not implement adequate measures to prevent infection. Under Section 483.80 of the Federal Code, nursing homes must work to mitigate the development and spread of disease by establishing and maintaining an infection prevention and control program. An April 2021 citation found that Collar City Nursing and Rehabilitation Center failed to ensure such. The citation specifically describes staff failures to ensure the maintenance of Covid-19 precautions. It goes on to recount instances in which two residents ‘were consistently leaving” a floor with a Covid-19 positive residents to visit a separate floor. It states further that the nursing home did not ensure staff on the Covid-19 floor donned personal protective equipment or performed hand hygiene procedures before and after resident encounters. A plan of correction undertaken by the facility included the re-education of relevant staff on the use of hand hygiene and PPE, as well as the maintaining of quarantine status during an outbreak.

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

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