Following a December, 2013 certification survey during which the Department of Health found a significant medication error, Hill Haven, an upstate New York nursing home, has been fined $77,935.00. The fine comes in the form of a Federal Civil Money Penalty, used by state and federal governments when a nursing home does not adhere to minimum standards of care.
The Department of Health conducted the survey leading to the fine on December 6, 2013. The reason for the steep amount of the monetary penalty could be that one violation documented, failure to ensure that residents are free from significant medication errors, was a repeat offense from a survey taken about a year earlier. The 2013 survey details the failure of the nursing home to provide a steroid used to control inflammatory diseases to a resident suffering from an inflammatory skin disorder.
Per physician’s orders, the resident in question was to receive the drug, Prednisone, on a daily basis while at the same time decreasing the dosage from the start of admission. After failing to administer the drug for a two day period roughly two weeks after admission, the resident required hospitalization. After the week long hospital stay, the resident was readmitted to Hill Haven. Again, the order stated that the patient was to receive the Prednisone, tapering the prescription level on a weekly basis. Despite both the order and the previous hospitalization due to failure to administer his medication, the nursing home again failed to provide the Prednisone to the patient. He was sent back to the hospital only seventeen days after his readmission to the nursing home.
Interviews conducted of the Registered Nurse Manager, attending physician, and Medical Director revealed that all were aware of serious side effects of abruptly stopping Prednisone usage. Additionally, and somewhat obviously, the facility’s policy stated that all medications were to be administered in accordance with physician orders.
Both state and federal regulations dictate that a nursing home must ensure that residents are free of any significant medication errors. Perhaps the simplest way to do this is to have a physician examine incoming residents, develop an individual medication plan, and communicate this plan via physician’s order to all other caregivers. When these orders are not followed by the nursing staff, residents can face serious consequences, including hospitalization and death. The Department of Health did not include in its survey the current state of the resident’s health.
The full report from the DOH can be found here on its website.