Brighton Manor
April 17, 2018 Complaint Survey

Standard Health Citations

FF11 483.45(f)(2):RESIDENTS ARE FREE OF SIGNIFICANT MED ERRORS

REGULATION: The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 17, 2018
Corrected date: June 6, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during an Abbreviated Survey (complaints #NY 906, #NY 662 and #NY 273) completed on 4/17/18, it was determined that for four (Residents #3, #4, #5 and #6) of four residents reviewed for medications, the facility did not ensure that each resident was free from significant medication errors. Specifically, multiple medications were not administered as ordered in a timely manner following admission to the facility or following physician orders/consult recommendations. This is evidenced by, but not limited to, the following: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Hospital discharge instructions, dated 10/24/17, included, but were not limited to, the following medications and instructions: a. [MEDICATION NAME] (used to treat high blood pressure and heart failure) 10 milligrams (mg) three times a day, last administered at 8:03 a.m., and next dose due on 10/24/17 at 4:00 p.m. and again at 10:00 p.m. b. [MEDICATION NAME] (high blood pressure medication) 37.5 mg twice daily, last administered at 8:04 a.m. with next dose due at 5:00 p.m. c. [MEDICATION NAME]-[MEDICATION NAME] nebulizer treatment ([MEDICAL CONDITION] medication) 0.5-2.5 mg/3 milliliter (ml), give 3 ml four times a day, last given at 8:08 a.m, and next doses due as ordered. d. [MEDICATION NAME] (heart failure medication) 60 mg twice daily with next dose due on 10/24/17 at 5:00 p.m. e. [MEDICATION NAME] ([MEDICAL CONDITION]/chest pain medication) 500 mg twice daily with next dose due on 10/24/17 at 5:00 p.m. f. [MEDICATION NAME] ([MEDICAL CONDITION] medication to improve breathing) inhaler two puffs twice daily with next dose due on 10/24/17 at 5:00 p.m. g. [MEDICATION NAME] (urine retention medication) 0.4 mg every evening, last administered on 10/23/17 at 8:53 p.m. with next dose due 10/24/17 at 9:00 p.m. Under instructions, the hospital discharge summary also includes instructions for the resident to be weighed daily and to notify the physician of an increase of 3 pounds in two days or 5 pounds in a week. Review of the facility medical record revealed the following: a. The admission record included that the resident was admitted to the facility from the hospital on [DATE] at 1:00 p.m. b. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. c. Only one weight was documented in the medical record from 10/24/17 through 11/3/17. d. Nursing progress notes revealed that the resident complained of chest pain requiring [MEDICATION NAME] tablets on 10/24/17 and 10/26/17 and shortness of breath on 10/28/17. e. A consultation follow-up report revealed that the resident was seen by her cardiologist on 11/1/17 due to increased [MEDICAL CONDITION] (swelling in her legs), increased shortness of breath, and increased confusion. [DIAGNOSES REDACTED]. f. The (MONTH) (YEAR) MARS revealed that the [MEDICATION NAME] was not administered until 11/2/17 at 9:00 a.m., and the [MEDICATION NAME] was continued to be given at 10 mg three times a day until 11/3/17 at 2:00 p.m., when the resident's family took the resident out of the facility against medical advice. There was no documentation that the facility medical team was notified of the cardiology recommendations to increase the [MEDICATION NAME]. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a consultation follow-up visit summary at the Diabetes Center, dated 8/11/17, revealed changes that included, but were not limited to, a change in the [MEDICATION NAME] from 40 units daily at bedtime to 65 units daily at bedtime. In a nursing progress note, written on 8/11/17 at 7:42 p.m., the Licensed Practical Nurse (LPN) documented that the resident returned from the Diabetes Center that day with new recommendations to monitor the resident's blood glucose levels before meals and at bedtime, [MEDICATION NAME] 36 units daily at bedtime, and to add a sliding scale insulin before meals. Review of facility physician orders, dated 8/11/17, revealed orders for [MEDICATION NAME] 40 units daily at bedtime. Review of an emergency room discharge summary, dated 8/15/17, revealed that the resident was sent to the emergency room for increased anxiety and acute [MEDICAL CONDITION] (infection) both [MEDICAL CONDITION] and bacterial of both eyes. Medication changes included the addition of [MEDICATION NAME]-[MEDICATION NAME] b (antibiotic drops) ophthalmic (eye) solution and directions to administer one drop into both eyes four times a day for seven days. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) MARS revealed that 36 units of [MEDICATION NAME] was administered to the resident at bedtime from 8/11/17 through her discharge on 9/13/17. The antibiotic eye drops were administered from 8/16/17 through 6:00 a.m. on 9/13/17 (29 days as opposed to the ordered 7 days). There was no documentation in the medical record to indicate the reason for the discrepancy in the orders and administration of the [MEDICATION NAME] or the antibiotic eye drops. The resident was discharged from the facility to the hospital on [DATE] for nausea and vomiting for three days. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary, dated 2/21/18, included [MEDICATION NAME]-[MEDICATION NAME] 0.5-2.5 mg/3 ml, give 3 ml by nebulizer four times daily for [MEDICAL CONDITION] with the next dose due on 2/21/18 at 1:00 p.m., and [MEDICATION NAME] (medication used for nerve pain) 300 mg three times daily with the next dose due on 2/21/18 at 5:00 p.m. Review of the (MONTH) (YEAR) MARS revealed the 4:30 p.m. and the 9:00 p.m. dose of the [MEDICATION NAME] was documented as not administered, and the 2:00 p.m. and 10:00 p.m. doses of [MEDICATION NAME] were not administered as the medication was not available. The nursing admission assessment, dated 2/21/18, included that the resident was admitted to the facility on [DATE] at 11:00 a.m. The note included that the resident was on oxygen, had rales (abnormal crackling sounds in the lungs of residents with respiratory disease as heard with a stethoscope) throughout the lung fields but was not in respiratory distress. Under pain the admission assessment was left blank. Interviews conducted on 4/16/18 included the following: a. At 10:40 a.m., the LPN/Unit Manager stated that when a resident is admitted from the hospital, the discharge summary is reviewed with the Nurse Practitioner (NP), orders put in the computer which automatically goes to the facility's contracted pharmacy. She said that she also faxes the orders and calls the pharmacy as a follow-up but does not know if everyone does that. She said the medications are supposed to be delivered to the facility on the evening run which is usually around 5:00 p.m. She said that sometimes the drug delivery does not get to the facility until 11:00 p.m. She said if the medications do not come in the evening, then the medical team should be notified. b. At 12:00 p.m., the LPN/Medication Nurse stated that he often worked the evening shift and that the medications get dropped off around 8:00 p.m. or more frequently 11:00 p.m. The LPN said that if medications are not sent, then staff should call the NP and get instructions. The LPN said that some of the medications are in the emergency box but not many. The LPN said that when a resident comes back from a consult, the recommendations are called into the NP, reviewed with them, and then the verbal orders are entered into the computer. c. At approximately 1:00 p.m., the Director of Nursing (DON) and the Administrator stated that it was their expectation that the medications should arrive at the facility in the evening for residents admitted as early as 11:00 a.m. and 1:00 p.m. They said if the medications do not arrive, then the NP should be notified. The DON said she did not have any Incident/Accident Reports for Residents #4, #5 or #6 and was not aware of any medication errors. (10 NYCRR 415.12(m)(2))

Plan of Correction: ApprovedMay 4, 2018

Corrective Action Taken for Those Residents Affected:
The licensed staff were educated regarding their responsibility to ensure accuracy and thoughoulon of all physician orders. A review of all physician orders, including consulting physicians, for the past 6 months, was conducted by the unit managers and DON. The residents affected by this deficient practice are no longer residing at this facility and have been discharged .
Corrective Action Taken for Those Residents Having Potential to be Affected-
The facility respectfully recognizes all residents as having potential to be affected and it was determined through staff and resident interviews and record reviews that there was no negative outcome due to the deficient practice. A full house review of medication orders was completed to ensure accuracy of the order transcription. A full house review of all weight orders was completed to ensure orders are being followed. A full house review of consultation orders was completed to ensure their accuracy.
Systemic Monitoring-
The policy for medication administration was reviewed, revised and updated to include specific steps to be taken when a medication is not available.  The In-Service Coordinator will be responsible to in-service all staff regarding the policy.
The policy for new admission orders [REDACTED]. The In-Service Coordinator will be responsible to in-service all staff regarding the policy.
The policy for weights was reviewed, revised and updated to include the need to contact the DON immediately when a physician ordered weight is not obtained. This action will result in disciplinary action up to and including termination.
The policy for consultation orders was reviewed, revised and updated to include a requirement of a second check and sign off for accuracy of the inputted orders. The In-Service Coordinator will be responsible to in-service all staff regarding the policy.
Quality Assurance Monitoring-
The facility will develop an audit tool to monitor and ensure compliance with the policy for medication administration.  The audit will administration of medication, lack of administration, reason for lack of administration and that staff verbalize understanding regarding the policy.  The unit manager or designee will be responsible to complete these audits weekly for 12 weeks and then monthly for 9 months.  The Director of Nursing will report findings at the QACM monthly for follow up and review. 
The facility will develop and audit tool to monitor and ensure compliance with the policy for new admission orders [REDACTED]  The audit will include review for accuracy of new admission orders [REDACTED].  The Unit Managers or designee will be responsible to complete these audits weekly for 12 weeks and then monthly for 9 months.  The Director of Nursing will report finding at the QACM monthly for follow up and review.
The facility will develop and audit tool to monitor and ensure compliance with the policy for consultation orders.  The audit will include review for accuracy and completion of a second check for the new orders and that staff verbalize understanding regarding the policy.  The Unit Managers or designee will be responsible to complete these audits weekly for 12 weeks and then monthly for 9 months.  The Director of Nursing will report finding at the QACM monthly for follow up and review.
The facility will develop and audit tool to monitor and ensure compliance with the policy for weights.  The audit will include review for completion of physician orders, the need to report a weight to the physician and that staff verbalize understanding regarding the policy.  The Unit Managers or designee will be responsible to complete these audits weekly for 12 weeks and then monthly for 9 months.  The Director of Nursing will report finding at the QACM monthly for follow up and review.

Person Responsible for the Correction of this Deficiency- Director of Nursing
Date of Completion- 06/06/18