In an April complaint survey, the Department of Health reported that Silvercrest, a Jamaica, Queens based nursing home, failed to ensure that its residents were free of significant medication errors. This failure was noted in one out of three sampled residents.
By physician’s orders, the staff was to administer medication to the resident in question once daily. Initially, the prescription was twice daily, however the physician altered this in the second order about one week after the first. Despite this change in prescription, staff at the facility continued the medication regimen twice daily for approximately one month after the order change. Subsequent interviews of the nursing staff uncovered a pattern of miscommunication within the facility. In some instances the night staff was unaware that the day staff had already medicated the resident. In others, the staff simply did not fully read the physician’s orders. The Assistant Director of Nursing stipulated that the nursing staff did not adhere to the nursing home’s own policies and procedures. Had they acted with more diligence, this error could have been avoided.
The Code of Federal Regulations states that the facility must ensure that residents are free from any significant medication errors. Certainly doubling the dose of medication that a physician prescribes falls under the category of “significant.” The medication in question was a diuretic, and as such could have led to dehydration, nausea, or other serious side effects. The DOH report states that this incident did not leave the patient in immediate jeopardy, but the potential for more than serious harm was certainly present.
The report by the Department of Health can be accessed here.