Gowanda Rehabilitation & Nursing Cited for Pressure Ulcer, Fall

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A nursing home in Gowanda, New York has received citations for violations of health and safety code.

Gowanda Rehabilitation & Nursing Center received 28 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on August 14, 2021. The Long Beach nursing home’s citations resulted from a total of six surveys by state inspectors. The violations they describe include the following:

1. The nursing home did not provide adequate pressure ulcer care. Under Section 483.25 of the Federal Code, nursing homes are required to provide residents with professional levels of care to promote the healing and prevent the infection of pressure ulcers. A May 2019 citation found that Gowanda Rehabilitation & Nursing Center failed to ensure such for two residents. The citation states specifically that there was no “weekly assessment by a qualified person after a pressure area was identified” for one resident, and that for the other there was “a five-day delay in assessment  by a qualified person” following the identification of a pressure area. A plan of correction undertaken by the facility included a full-house audit, the revision of the facility’s skin care protocol, and the educational counseling of nursing staff who did not properly document a resident’s pressure area.

2. The nursing home did not employ adequate measures to prevent accidents. Under Section 483.25 of the Federal Code, nursing homes are required to maintain resident environments as free as possible of accident hazards and to provide residents with adequate levels of supervision to prevent accidents. An October 2019 citation found that Gowanda Rehabilitation & Nursing Center failed to ensure such. The citation specifically describes a resident who “was observed smoking and not utilizing a smoking apron per their plan of care,” and another resident whose non-slip device was not put in place after a fall, per their care plan, which the resident states further was not revised after the resident’s fall. A plan of correction undertaken by the facility included the counseling of relevant staff.

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The New York nursing home’s citations describe medication errors and deficient pressure ulcer care.

3. The nursing home did not adequately prevent medication errors. Section 483.45 of the Federal Code stipulates that nursing homes must keep medication error rates below five percent. A July 2018 citation found that Gowanda Rehabilitation & Nursing Center failed to ensure such. The citation specifically describes two medication errors out of 25 medication opportunities in connection to one resident, resulting in an error rate of eight percent. According to the citation, the errors in question “involved medications that were crushed prior to administration that were not to be crushed.” In an interview, the nurse who administered the medication “stated he did not notice the yellow sticker on the blister packs that said not to crush the medications.” A plan of correction undertaken by the facility included the in-servicing of licensed nursing staff.

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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