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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 12, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the abbreviated survey (NY 729), the facility failed to ensure the resident was free of significant medication errors. This was evident for one (1) out of three (3) residents sampled (Resident #1). Specifically, on 09/06/2024, Licensed Practical Nurse #1 administered 150 milligrams of [MEDICATION NAME] instead of 35 milligrams of [MEDICATION NAME] to Resident #1. Resident #1 was alert and stable with no complaints of pain or discomfort and was escorted for scheduled [MEDICAL TREATMENT] therapy. The findings are: The Facility Policy and Procedure titled Medication Administration, dated (MONTH) 2023, documented the purpose of the policy is to ensure that residents receive medications in a safe and efficient manner and to avoid medication errors include wrong resident, wrong dose and wrong time. The Facility Policy and Procedure titled Medication Administration, reviewed and updated (MONTH) 2024, included details of the five rights for prevention of medication errors and specifies the facility's hours of medication administration. The Facility's Occurrence Investigation dated 09/06/2024, documented on (MONTH) 6, 2024, Licensed Practical Nurse #1 administered medications to Resident #1 which included [MEDICATION NAME] liquid, at approximately 8:00 AM prior to going to [MEDICAL TREATMENT]. Resident #1 left the facility for [MEDICAL TREATMENT] without any complaints. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 09/05/2024, documented Resident #1 as cogitatively intact but required assistance with most activities of daily living. A Physician order [REDACTED].#1 was [MEDICATION NAME], 10 milligrams per milliliter oral concentrate, give 3.5 milliliters/ 35 milligrams by oral route once daily. Scheduled every day at 9:00 AM. Medication Administration Records of Resident #1 dated (MONTH) 6, 2024, documented Licensed Practical Nurse #1's signature indicating [MEDICATION NAME] solution was administered by Licensed Practical Nurse #1. A Baseline Care Plans dated 09/03/2024, documented intervention to offer all medications as prescribed by the Medical Doctor. A Progress note 09/06/2024 at 10:40 AM, written by Registered Nursing Supervisor #1 documented on 09/06/2024 at approximately 9:00 AM, Licensed Practical Nurse #1 reported Resident #1 received the wrong dose of [MEDICATION NAME]. Resident #1's dose was 35 milligrams liquid [MEDICATION NAME] daily but was given a dose of 150 milligrams that belonged to Resident #2. Resident #1 was picked up at 8:09 AM, and transported to the center for [MEDICAL TREATMENT]. Nurse Supervisor #1 informed the [MEDICAL TREATMENT] center of the medication error. Resident #1's adult child (the Complainant), the attending physician, and the social worker were informed. A Progress Note date 09/06/2024 at 8:53 AM, written by Registered Nurse Supervisor #2 documented Resident #1 went to [MEDICAL TREATMENT] at 8:09 AM, transported by ambulette. Blood Pressure was 80/54, Temperature was 97.2 degrees Fahrenheit and Respirations were 18. Resident was alert and responsive. Licensed Practical Nurse #1 left the faciity on [DATE], without providing the facility with a written statement and did not return to the facility. During a telephone interview on 02/14/2025 at 3:37 PM, the Attending Physician #1 at the nursing home stated Resident #1 was in the facility for three days with several comorbidities and therefore there was a potential that a higher dosage of [MEDICATION NAME] could impact Resident #1 clinical status. [MEDICATION NAME] was available that could have been given, if it was known that the Resident #1 received the higher dosage before leaving for [MEDICAL TREATMENT]. The resident was transferred to the hospital from the [MEDICAL TREATMENT] center and was no longer under the care of the nursing home attending physician. During an interview on 2/14/2025 at 2:37 PM, Nurse Supervisor #1 stated on 09/06/2024 at about 9:00 AM, Resident #2, who is on [MEDICATION NAME] informed them someone was taking their [MEDICATION NAME]. Licensed Practical Nurse #1 informed Nurse Supervisor #1 the wrong dose was given to Resident #1. Resident #1 had already left for [MEDICAL TREATMENT]. The Director of Nursing was informed, the [MEDICAL TREATMENT] center was called, but Resident #1 had not yet arrived at the center. Nurse Supervisor #1 also stated the [MEDICATION NAME] was stored in each resident's individual bag and is locked in a cabinet separate from other narcotics. The liquid in the bottles of [MEDICATION NAME] is visible and the resident's name is at the top of the bottle. During an interview on 2/14/2025 at 3:20 PM, the Director of Nursing stated Registered Nurse Supervisor #1 notified them of the medication error, and an investigation was started immediately. [MEDICATION NAME] medication bottles are labelled by the clinic the resident usually attends in the community. The Director of Nursing stated they requested Licensed Practical Nurse #1 to write a statement before leaving on 09/06/2024 but it was not done. A verbal statement written by the Director of Nursing stated Licensed Practical Nurse #1 was unsure which name was seen on the bottle of [MEDICATION NAME] from which Resident #1was given the [MEDICATION NAME]. During a telephone interview on 2/20/2025 at 4:36 PM, Licensed Practical Nurse #1 responded and identifying themselves as Licensed Practical Nurse #1, but after being informed of reason for the call, they ended the call. 10 NYCRR 415.11(c)(3)(i) Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement on 09/19/2024, prior to and during the time of this survey. A Plan of Correction was not required for this citation. The facility took corrective actions and was found to be in substantial compliance prior to the surveyor's onsite visit on 2/14/2025. The facility immediately called the [MEDICAL TREATMENT] center and informed them of the medication error as the resident was already in transit to the center. Licensed Practical Nurse #1 was removed from the schedule and their agency contacted. Office of Professions was notified. The Policy on Medication Administration in effect on (MONTH) 6, 2024, was revised and updated. The Facility provided in-service to all Registered Nurses and Licensed Practical Nurses on the five Rights of medication administration on 9/6-9/18/2024, and was ongoing for any new staff. The facility performed Audits of Medication Records weekly for eight weeks and no issues were identified. Audits were done monthly for three months and there were no irregularities. A Quality Assurance Performance Improvement Meeting was held 9/19/2024 to discussed [MEDICATION NAME] and medication administration. Four Licensed Practical Nurses and three Registered Nurses stated that they are knowledgeable about the Medication Administration Policy and the five rights to prevent medication errors. There were no further reported medication errors. | Plan of Correction: ApprovedMarch 21, 2025 A plan of correction is not required for past non compliance deficiencies. The facility remains responsible to expeditiously correct all deficiencies and to ensure measures are in place to maintain compliance. Signed by: (NAME)Rosenberg Administrator 3/21/2025 |