Glens Falls Center: Nursing Home Cited for Medication Errors

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Glen Falls Center for Rehabilitation and Nursing had a total of 8 inspections by state surveyors that resulted in 32 citations for being in violation of public health code between 2018 and 2022.

Glens Falls Center for Rehabilitation and Nursing received 32 citations for violations of public health code between 2018 and 2022, according to New York State Department of Health records accessed on May 25, 2022. The Glens Falls nursing home’s citations resulted from a total of 8 inspections by state surveyors. The violations they describe include the following:

1. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code ensures nursing home residents the right to be “free of any significant medication errors.” An August 2021 citation found that Glens Falls Center for Rehabilitation and Nursing failed to ensure such. The citation specifically describes an instance in which a resident “was administered another resident’s medications that included the significant medications including: antidepressants, insulin, a narcotic pain medication, a blood thinner, and cardiac medication.” As a result of this, the resident erroneously administered these medications “was transferred to the emergency room for evaluation.” A plan of correction undertaken by the facility included the re-education of nursing staff on the facility’s Medication Administration policy.

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Glen Falls Center did not prevent medication errors, they did not ensure that the residents were free from physical restraints, and the nursing home did not provide sufficient pain management to the residents that needed those services.

2. The nursing home did not adequately ensure residents were free from physical restraints. Section 483.10 of the Federal Code stipulates that nursing home residents have the right “to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” A May 2021 citation found that Glens Falls Center for Rehabilitation and Nursing failed to ensure such. The citation specifically describes an instance in which a resident “was restrained in a chair with a sheet tied with a knot at the back of the chair in a manner that the resident was unable to untie the sheet.” As the citation goes on to explain, facility policy prohibited the use of “bed sheets as restraints,” and a review of the resident’s records showed “no physician order identifying the medical symptom being treated with a restraint.” In an interview, the facility’s Administrator said that the sheet should not have been tied around the resident, and that a doctor’s order “was necessary to place a restraint on a resident.” A plan of correction undertaken by the facility included the re-education of staff on policies regarding restraint use, abuse, and resident rights.

3. The nursing home did not provide adequate pain management. Under Section 483.25 of the Federal Code, nursing homes are required to “ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.” A November 2021 citation found that Glens Falls Center for Rehabilitation and Nursing failed to ensure such. The citation specifically describes a resident who received a narcotic pain medication on 20 instances “with no documented monitoring to determine the medication’s effectiveness.” Nor, the citation states, was there any “Comprehensive Care Plan with goals and interventions to address” the resident’s pain. In an interview, the facility’s Director of Nursing said that “there should have been a comprehensive care plan in place to address [the resident]’s pain or alteration in comfort since they were using pain medication.” A plan of correction undertaken by the facility included the education of LPNs and RNs.

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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