The N.Y.S. Department of Health reported that it had fined Parker Jewish Institute for Health Care and Rehab, a Queens nursing home, twelve thousand dollars. The fine stems from an incident discovered by the DOH during an inspection in July, 2011.
During the July inspection, investigators gave the facility the most severe rating in two areas of nursing home neglect. When a nursing home receives four out of four on the DOH severity scale, it means that the Department feels that residents were put in immediate jeopardy by the actions, or inaction, of the home. Here, the violations involved a medication error that caused the hospitalization of a patient.
The patient involved in the incident had been admitted to Parker Institute for short term rehabilitation. On intake, it was noted that the woman was diabetic. Upon admission, administration of insulin was ordered, however the physician did not note the specific dosage that the resident required. The incomplete physician’s order resulted in the woman receiving a higher dose of insulin than she should have been given. The resident was hospitalized, and ultimately died, less than one week after her admission to Parker Institute.
The outcome of this unfortunate incident reinforces the need for stringent record keeping in all nursing homes and long term care facilities. Certainly Parker Institute could have complied with the section of the Code of Federal Regulations mandating the avoidance of significant medication errors had it ensured proper documentation upon intake. The facility issued suspensions and education to the parties involved, but obviously too late to help the victim of this occurrence.
The Department of Health deficiency report can be accessed here.