As part of a routine certification survey conducted in September 2013, officials with the New York State Department of Health (DOH) fined the Lutheran Retirement Home, a 174-bed facility located in Jamestown, New York, for numerous deficiencies, including keeping expired medications to be given to patients. DOH inspectors discovered that all four units of the nursing home failed to discard expired medications such as vitamins, cough medicine, aspirin and antacids. In two instances, surveyors even observed that several medication carts, used by nurses to dispense medications, contained expired controlled substances used to treat anxiety.
When asked about the expired medications, a licensed practical nurse (LPN) told investigators that the facility did not have a policy in place to check expiration dates on medications. However, a nursing supervisor states that nurses on the night shift are responsible for clearing the shelves in the medication room of any expired items. The pharmacist at the facility stated that nurses often tell him that “they are too busy to do this.” Furthermore, the pharmacist stated that nurses should destroy expired controlled substances in accordance with state and federal regulations and guidelines.
DOH surveyors also observed two nurses pass a key to the safe storing narcotics without ever counting the controlled substances in the safe as is standard practice and procedure. An LPN told a DOH investigator that “they are busy and cannot do it that way.” After hearing about the incident, the pharmacist stated, “We have to stop that right away.” As a result of these findings pertaining to the medications, the DOH concluded that “the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date…and permit only authorized personnel to have access to the keys.”
During the same certification survey, DOH officials also cited the facility for failing to keep an environment that was free of accident hazards. At the time of the inspection, one of the building’s units, located on the second floor, was in the process of being renovated. To facilitate the removal of debris from the facility, construction workers removed two windows to create a five foot long by two foot wide opening. Workers used this opening to throw out construction debris rather than carting it throughout the entire building. When the opening was not in use, workers simply covered it with a piece of plywood that was loosely secured by a rope. A DOH inspector touched the plywood and determined that it could easily be pushed out or removed. The surveyor conclude that 28 residents in the unit, including 11 who were cognitively impaired could have leaned against the plywood and fallen two stories to the cement pavement. The DOH report concluded, “These deficiencies and the potential serious impact they represent to the quality of care and the quality of life of facility residents, demonstrate a failure…to ensure effective management and operation of the facility.”