In a complaint survey dated March 22, 2012, the Department of Health noted that Friedwald Center for Rehabilitation and Nursing, a Rockland County nursing home, failed to keep the facility free of potential accident hazards. The survey illustrates three incidents with potential to cause more than serious harm to residents.
One resident, an aspiration risk, was meant to be on a “ground diet,” whereby his food would be blended into a thick liquid form before consumption. This reduces the risk of the resident choking. A physician’s order upon admission did not note the necessity of a ground diet. In a separate incident, surveyors noticed an unattended and unlocked medicine cart. The condition of the cart left the medications stored within accessible to passersby. The final accident hazard involved suction machines unplugged and/or inaccessible during meals in the dining room. If a situation needing the machines had arisen during mealtime, the units would not have been ready for use.
As codified in the CFR, a “facility must ensure that the resident environment remains as free of accident hazards as possible.” 42 CFR 483.25(h). The scenarios detailed above create the possibility for two common forms of nursing home accidents, choking and medication errors. Fortunately for the facility and its residents an actual accident did not arise from these incidents. Perhaps with this warning from the DOH, the facility will be more diligent in the future to create a safer environment for its residents. A copy of the full report can be found here.