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Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 19, 2020
Corrected date: January 8, 2021
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY 590) the facility did not ensure residents on 1 of 5 Units (Unit 7) were free from significant medication errors. Specifically, Residents #1, 4, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28 on Unit 7C did not receive medications as ordered. Findings include: The facility policy Medication Administration revised 4/2020 documented any prescription medication not administered or held must be reported during the shift to the physician/nurse practitioner. Medications omitted due to refusal by resident or withheld due to other circumstances must be documented on the EMAR. 1) Resident #12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired and the resident had a feeding tube. The staffing sheet documented licensed practical nurse (LPN) #13 was the night nurse (11 PM on 10/31/2020 to 7 AM on 11/1/2020) for Unit 7C and on 11/1/2020, the day shift nurse (7 AM to 3 PM) was documented to be Assistant Director of Nursing (ADON) #14 starting at 1 PM. The 11/1/2020 Medication Administration Record (MAR) documented the following medications were not administered to Resident #12 on 11/1/2020: - At 9 AM, [MEDICATION NAME] (reflux medication), 2 milligrams (mg)/milliliter (ml), 20 ml; Reguloid (fiber supplement), 63% powder, 1 tablespoon; Quetiapine (anti-psychotic), 25 mg; Ropinirole (restless leg syndrome medication), 0.25 mg; [MEDICATION NAME] (blood pressure), 10 mg, and [MEDICATION NAME] (psychoactive medication) 500 mg/ml syrup, 200 mg. - At 10 AM, [MEDICATION NAME] 1.5 calorie (tube feeding), 237 ml bolus and 50 ml water flush before and after tube feeding. There were no nursing progress notes on 11/1/2020 addressing the medications that were not given or that the medical provider was notified of the missed medication administrations. On 11/9/2020 at 12:18 PM, the Director of Nursing (DON) stated there was an agency licensed practical nurse (LPN) who worked from 11 PM on 10/31/2020 to 7 AM on 11/1/2020. The DON stated she thought the agency LPN stayed into the day shift on 11/1/2020 and administered morning medications to the residents and then left the facility without a relief nurse to take over. She stated after the agency LPN left, the ADON came in and took over the medication pass on 7C. On 11/9/2020 at 1:27 PM, Staffing Coordinator #8 stated in an interview, on the morning of 11/1/2020, the agency LPN (LPN #13) came to her, gave her the keys to 7C, and stated she was leaving. There was no relief nurse so Staffing Coordinator #8 told her she could not leave but she left anyway. LPN #13 told Staffing Coordinator #8 she did not pass medications and Staffing Coordinator #8 notified the DON, ADON and the registered nurse Supervisor (RNS) in the building. The DON and ADON agreed to come in. Later in the shift, LPN #10 came to her (she was working on another unit) and took the keys to 7C so that she could do the tube feedings. On 11/9/2020 at 2:05 PM, ADON #14 stated in an interview, on 11/1/2020, he was called at around 10:30-11 AM, he thought by the DON, and was asked to come in. He came in around 1 PM to 1:30 PM and there was a nurse on 7C administering tube feedings. He did not know if she passed any medications. If medications were not given, there should be a progress note documenting that and a follow up call to a medical provider. He stated when he took over, he started administering the medications that were due at 2 PM and later. On 11/9/2020 at 2:41 PM, LPN #10 stated on 11/1/2020, she was working on Unit 4 and went to 7C to do tube feedings because she heard those residents had not been fed yet. At around 12:30 PM, ADON #14 came in and took over for her. On 11/9/2020 at 3:02 PM, the DON was re-interviewed. She stated she did not look into medication issue on 11/1 because the ADON told her all medications were passed and there were no issues. LPN #13 was interviewed via telephone on 11/19/2020 at 10:55 AM and stated she was scheduled to work from 11 PM on 10/31/2020 to 7 AM on 11/1/2020. She administered the 6:00 AM medications for all residents on 7C and was told the relief nurse was not coming at 7 AM. She was told the DON and ADON were coming in to take over so at around 8:15 AM, she went to the staffing office and handed over the medication keys to the staffing person. She did not complete the 8:00 AM medication pass and did not specifically tell anyone the 8:00 AM medication pass was not completed. 2) Resident #18 had [DIAGNOSES REDACTED]. The 7/8/2020 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and the resident had a feeding tube. The staffing sheet documented licensed practical nurse (LPN) #13 was the night nurse (11 PM on 10/31/2020 to 7 AM on 11/1/2020) for Unit 7C. On 11/1/2020, the day shift nurse (7 AM to 3 PM) was Assistant Director of Nursing (ADON) #14 starting at 1 PM. The 11/1/2020 Medication Administration Record (MAR) documented the following medications were not administered on 11/1/2020: - At 7:00 AM, [MEDICATION NAME] sulfate 1% solution (eye drops), 2 drops. - At 9 AM, [MEDICATION NAME] (benign intercranial hypertension) 250 mg tablet, 2 tablets; [MEDICATION NAME] (iron), 220 mg/5 ml [MEDICATION NAME], 7.5 ml; [MEDICATION NAME] (blood pressure), 5 mg; artificial tears 1.4% (eye drops), 1 drop each eye; [MEDICATION NAME] (cough syrup), 100 mg/5 ml, 20 ml dose; trans-scop patch (nausea/emesis medication), 1.5 mg patch; Calcitrol (calcium supplement), 1 microgram (mcg)/ml solution, 0.5 ml; Calcium Acetate (calcium supplement), 667 mg capsule, and Active Critical Care Liquid (protein supplement), 30 ml. - At 1 PM, 150 ml water flush via the feeding tube. - At 2 PM, [MEDICATION NAME] 1.5 calorie (tube feeding) 237 ml bolus and 30 ml water flush. There were no nursing progress notes on 11/1/2020 documenting the medications that were not given, a rationale for not administering them and documentation the medical provider was notified. On 11/9/2020 at 12:18 PM, the Director of Nursing (DON) stated there was an agency licensed practical nurse (LPN) who worked from 11 PM on 10/31/2020 to 7 AM on 11/1/2020. The DON thought the agency LPN stayed into the day shift on 11/1/2020, administered morning medications, and then left when there was no relief nurse. She stated the ADON took over for the agency LPN and completed the medication pass on 7C. On 11/9/2020 at 1:27 PM, Staffing Coordinator #8 stated in an interview, in the morning of 11/1/2020, the agency LPN (LPN #13) came to her, gave her the keys to 7C, and stated she was leaving. There was no relief nurse so Staffing Coordinator #8 told her she could not leave but she left anyway. LPN #13 told Staffing Coordinator #8 she did not pass medications and Staffing Coordinator #8 notified the DON, ADON and the registered nurse Supervisor (RNS) in the building. The DON and ADON agreed to come in. Later in the shift, LPN #10 came to her (she was working on another unit) and took the keys to 7C so that she could do the tube feedings. On 11/9/2020 at 2:05 PM, ADON #14 stated in an interview, on 11/1/2020, he was called at around 10:30-11 AM, he thought by the DON, and was asked to come in. He came in around 1 PM to 1:30 PM and there was a nurse on 7C doing tube feedings. He did not know if she passed any medications and if mediations were not given, there should be a progress note documenting that and a follow up call to a provider. He stated when he took over, he started administering the medications that were due at 2 PM and later. In an interview on 11/9/2020 at 2:41 PM, LPN #10 stated on 11/1/2020, she was working on Unit 4 and went up to 7C to do tube feedings because she heard those residents had not been fed yet that day. At around 12:30 PM, ADON #14 came in and took over for her. On 11/9/2020 at 3:02 PM, DON re-interviewed, did not look into med issue on 11/1 because ADON told her all medications were passes and there were no issues. LPN #13 was interviewed via telephone on 11/19/2020 at 10:55 AM and stated she was scheduled to work from 11 PM on 10/31/2020 to 7 AM on 11/1/2020. She administered the 6:00 AM medications for all residents on 7C and was told the relief nurse was not coming at 7 AM. She was told the DON and ADON were coming in to take over so at around 8:15 AM, she went to the staffing office and handed over the keys to the staffing person. She did not complete the 8:00 AM medication pass and did not specifically tell anyone the 8:00 AM medication pass was not completed. 3)Resident #1 had [DIAGNOSES REDACTED]. The 10/19/2020 Minimum Data Set (MDS) assessment documented the resident's cognition was intact. The staffing form documented the night nurse (11 PM on 10/30/2020 to 7 AM on 10/31/2020) was licensed practical nurse (LPN) #18 and the day LPN on 10/31/2020 (7 AM to 3 PM) was LPN #16. The 10/31/2020 Medication Administration Record (MAR) documented the following were not administered: - At 6 AM, 2 Cal HN (tube feeding), 300 milliliters (ml) bolus. - At 6 AM, 90 ml water flush before and after tube feeding. There were no nursing progress notes on 10/31/2020 addressing the tube feeding not being administered. On 11/5/2020 at 9:25 AM, respiratory therapist #15 stated in an interview, on 10/31/2020, she saw the resident at around 10 AM to complete [MEDICAL CONDITION] care. At that time, she noticed the resident's tube feeding had not been given that day. She told LPN #16 but LPN #16 stated that is was supposed to be done on the night shift, this was now the day shift and she had to administer the day orders. LPN #16 stated she would get to the resident when she made it to their room. She stated the RNS #17 was on the unit, so she told her. RNS #17 told her she was unable to assist as she had an incident report to do and other things to take care of. LPN #18 was interviewed via telephone on 11/19/2020 at 10:34 AM and stated she worked in the facility on the night shift on 10/30/2020 and worked on the seventh floor. She stated she thought she administered all medications and tube feeding that showed up on her computer and she did not recall any tube feedings that were ordered being missed by her that date. LPN #16 was interviewed on 11/19/2020 at 11:09 AM and stated she worked the day shift from 7:00 AM to 3:00 PM on 10/31/2020. She was informed by the respiratory therapist the resident did not receive their tube feeding on 10/31/2020 at 6 AM. She checked the MAR and there were no scheduled tube feedings on the day shift but she identified there was an order for [REDACTED]. At some point that day, she administered the resident's tube feeding. She did not document she administered the resident's tube feeding as there was no way to document it on the MAR late and she was not sure how to find the nursing notes to document that information as the facility had a new medical record system. 10NYCRR 415.12(m)(2) | Plan of Correction: ApprovedDecember 3, 2020 F-760 Residents are Free of Significant Med Errors What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents #4, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27 and 28 were assessed by the RN with no negative outcome as a result of no nurse assigned to medication administration. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same practice. Scheduling staff and RN managers/supervisors have been re-educated regarding the process to follow if a unit does not have an assigned nurse to administer medications. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? Medication Administration Reports will be run and reviewed every shift by the RN manager/supervisor and any resident identified with missed medications will be assessed by the RN manager/supervisor. The RN will notify the medical provider. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Reports of missed treatments will be run daily and appropriate corrective action will be taken and documented as indicated. Results of the MAR indicated [REDACTED]. Correction Date: January 8, 2021 Overseen by: Director of Nursing |