In November 2013, the NYS DOH cited Rosewood Rehabilitation and Nursing Center, an 80-bed nursing home located in Rensselaer, New York, for failing to take appropriate actions against a licensed practical nurse who may have diverted narcotics from patients for her own personal use. The investigation concluded that the problem was “widespread” and place residents in “immediate jeopardy.”
The DOH report claims that a licensed practical nurse (LPN) may have stolen pain medication in September 2013 from a resident suffering from a broken femur and chronic obstructive pulmonary disease (COPD). While working the night shift, a nursing supervisor observed that the LPN failed to sign a form indicating that she had administered hydrocodone and oxycodone medication to a patient. When the supervisor question the LPN as to why she hadn’t done so, the LPN stated that she would do it later. When the LPN returned from her break, the supervisor noticed that the woman’s nose was running and kept “sniffing inward,” a potential sign that the LPN had crushed up pills and snorted them. In addition, the supervisor noted that the resident with the broken leg complained that he was not “feeling the effects of his narcotics, as he normally does” and was unable to sleep. Even though the supervisor suspected that the LPN had taken the patient’s narcotics, the supervisor allowed the woman to continue working her shift. The incident was never reported to the DOH or the Bureau of Narcotic Enforcement for further investigation. The LPN later resigned and was asked not to come back to the facility.
In a separate incident involving the same LPN, two fentanyl patches went missing. While one of the patches was found a day later “crumbled up and on the floor” of the medication room, the other patch was never located. The fentanyl patches were for a resident who was diagnosed with hypertension, dysthymic disorder and neuropathy. The LPN had been involved in counting the patches. Another nurse, who had indicated that narcotics had gone missing before at the facility, stated that administrators were aware of the problem. In addition, the same nurse told investigators that the LPN in question had once offered her some pain medication for her back. The LPN in question even told the nurse that she could “get anything for her that she wanted.” While the Director of Nursing of the facility found that the missing patches were “suspicious” and “assumed” that the LPN had taken them, she never reported the incident to the DOH or the Bureau of Narcotic Enforcement as required by law.
The Rosewood facility received a “much below average” overall rating, according to the “Nursing Home Compare” website. In addition, the facility also received a “much below average” rating for health inspections and staffing levels. Rosewood received a total of 23 deficiency citations from the DOH; the average number of deficiencies for New York nursing homes is 5.4. Many of the deficiencies were considered widespread and placed the residents in immediate jeopardy of suffering harm or injury.