Crown Heights Center for Nursing and Rehabilitation Cited for Unnecessary Drugs

Crown Heights Center for Nursing and Rehabilitation received 26 citations for violations of public health code between 2015 and 2019, according to New York State Department of Health records accessed on January 16, 2020. The facility also received a 2012 fine of $10,000 in connection to findings it violated health code provisions regarding quality of care care; and a 2011 fine of $10,000 in connection to findings it violated health code provisions regarding accidents and supervision, administration, professional services, and significant medication errors. 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 residents’ drug regimens were free of unnecessary drugs. Under Section 483.45 of the Federal Code, nursing homes must keep “each resident’s drug regimen… free from unnecessary drugs.” A March 2017 citation found that Crown Heights Center for Nursing and Rehabilitation did not ensure a resident’s drug regimen was free of unnecessary drugs. The citation specifically found that the resident had been prescribed a certain medication absent a psychiatric evaluation, and “with no evidence of behaviors to support ongoing use” of the medication in question. The citation notes that the resident’s records contained no documentation indicating that they had been assessed by a psychiatrist or that the facility attempted a gradual dose reduction of the medication since the resident’s admission. A plan of correction undertaken by the facility included a psychiatric consult and an order to discontinue the medication.

2. The nursing home did not provide residents with adequate accident supervision. Section 483.25 of the Federal Code states that nursing homes must ensure residents receive adequate supervision and devices to prevent accidents. A March 2017 citation found that the nursing home did not provide each resident with adequate supervision and functioning equipment. The citation notes specifically that “a suction machine not being properly equipped for use in case of emergency” was observed in a dining room. An inspector observed the suction machine unplugged against the wall, with no tubing connected to it, and with no suction tip. When an inspector asked for a demonstration of the machine’s use, neither of two Licensed Practical Nurses were “able to attached [sic] the tubing to the machine,” with one leaving to retrieve correct tubing. The citation states that 15 minutes passed before the machine was properly ready for use, concluding that it “was not equipped for immediate use in the event of an emergency.”

3. The nursing home had a deficiency in its abuse and neglect policies. Section 483.13 of the Federal Code requires nursing homes to “develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.” A February 2016 citation, however, found that Crown Heights Center for Nursing Rehabilitation and Care “did not ensure that an investigation of an injury of unknown origin was initiated timely.” The citation notes specifically that during a family visit, the resident’s brother observed a large bruise on the resident’s upper arm. The resident’s family members reported the bruise to a Registered Nurse Supervisor and were informed it would be reported to a physician. The citation states that no documented evidence indicated he facility conducted an investigation of the injury following its reporting by the resident’s family members. The citation notes that this was contrary to facility’s policy providing for the thorough investigation of “all unexplained injuries,” including bruises.

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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