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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 5, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a Complaint Investigation (NY 323) the facility did not ensure they consulted with the resident's physician when there was a need to alter treatment significantly for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the facility did not ensure they consulted with the resident's physician when a medication was not administered as ordered, resulting in 20 missed doses. The finding is: The policy titled Medication/Treatment Administration Documentation, last revised 6/24, documented when medications or treatments are not available for administration as ordered inform the Nursing Supervisor immediately, Emergency medication kit is used, and the medical provider is notified, and immediate medication delivery is requested. The policy titled Change in Resident's Condition, Medication/Treatment or status, last revised 2/2025, documented the resident and/or responsible party and the attending physician are promptly notified in changes of care and resident condition. Nursing services will notify the resident's physician when a need to alter treatment significantly (discontinue or changes to an existing treatment due to adverse consequences, or to commence a new form of treatment). Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 1/24/24 documented Resident #1 was cognitively intact, understands, was usually understood and received an antipsychotic. Review of comprehensive care plan dated 11/3/21 documented Resident #1 had history of falls with an intervention that resident is known to intentionally place self on floor and crawl on knees, added on 2/24/ 23. The comprehensive care plan documented Resident #1 had a history of [REDACTED]. an overnight mental health stay at hospital on 4/4/ 23. Interventions included to monitor therapeutic effects and side effects and report to the provider as needed. The nursing progress note dated 1/24/24 at 3:15 PM, Licensed Practical Nurse Unit Manager #1 documented Resident #1 was seen by Psychiatrist/Neurologist with new order to receive Nuplazid (antipsychotic medication) 10 milligrams once daily at bedtime. Awaiting approval (from insurance). In a follow up note dated 1/31/24 at 4:32 PM, they documented the order for Nuplazid was approved for 14 days at a time. Review of a Psychiatry note dated 1/24/24, Resident #'1s Neurologist/Psychiatrist documented the resident was to start Nuplazid 10 milligrams due to continued behaviors of crawling on the floor, refusing and fighting with staff when they attempted to provide care. Review of the Order Summary Report printed 3/4/25, revealed an order for [REDACTED]. 24. The medication was not ordered from 3/28/24 to 4/11/24 and 4/26/24 to 4/30/ 24. There were no directions to contact the medical provider to have the medication reordered every 14 days. Review of Medication Administration Records dated (MONTH) 2024 - (MONTH) 2024 documented that there was no order in place for Nuplazid 10 milligrams at bedtime from 3/28/24 to 4/11/24 and 4/26/24 to 4/30/24 and the medication was not administered on these dates. Review of the nursing progress notes dated 3/28/24 to 4/10/24 and 4/26/24 to 4/30/24 revealed the medical provider was not updated regarding Resident #1's missed medication doses or the need to reorder the medication (Nuplazid). Review of the physician progress notes [REDACTED].#1 documented Resident #1 had a psychiatry consult on 3/6/24 and recommendations were followed. However, the resident's Nuplazid fell off after two weeks and would be resumed. physician progress notes [REDACTED]. The nursing progress note dated 4/11/24 at 2:52 PM, Licensed Practical Nurse Unit Manager #2 documented Resident #1 had a monthly physician visit and Nuplazid 10 milligrams daily was reordered. A note dated 4/11/24 at 2:57 PM, they documented Nuplazid must be reordered every 14 days per insurance, reorder on 4/12/ 24. During an interview on 3/4/25 at 1:26 PM, Licensed Practical Nurse Unit Manager #2 stated there had been an issue with the reordering process for Resident #1's Nuplazid due to insurance only covering a 14-day supply at a time. Every 14 days there had to be a new prescription written and signed off by the physician. During this time frame, Resident #1 had increased behaviors of placing themselves on the floor, was refusing their medication and was aggressive towards staff. They stated at the beginning of (MONTH) 2024 they realized they did not reorder Resident #1's Nuplazid and they went without it for a couple days. As soon as they realized the medication was not ordered, they contacted the doctor and had the order restarted. They stated they should have had a better system in place to remind them to call the provider as soon as the medication needed to be reordered. During an interview on 3/4/25 at 2:02 PM, Resident #1's Neurologist/Psychiatrist stated they ordered Resident #1 Nuplazid 10 milligrams daily and the resident should take it as ordered. Without the medication, Resident #1 became very dysfunctional and if taken properly could have prevented them from having increased behaviors leading to falls. They stated the facility should follow their protocols for updating their physician anytime there was a lapse in treatment. They would have expected to have been updated if the facility was unable to obtain the medication. During an interview on 3/4/25 at 2:16 PM, the Assistant Director of Nursing (interim Director of Nursing) stated Resident #1's Nuplazid was only able to be ordered every 14 days due to their insurance. Every 14 days a new prescription had to be entered and signed off by the physician. They stated the medication cart nurse was responsible for reordering medication and if they were unable to do so they should inform the unit manager. They stated at the end of (MONTH) 2024 to the beginning of (MONTH) 2024 they were in between unit managers for the unit and that is possibly how the medication fell off. They stated the physician should have been made aware as soon as the medication needed to be reordered so that it could be administered accordingly. The physician should have been updated on any missed doses of medications. The resident should be assessed for any adverse effects. If anyone goes without their antipsychotic for any amount of time, there were risks to the resident. During an interview on 3/4/25 at 2:45 PM, Licensed Practical Nurse Unit Manager #1 stated they were the unit manager in (MONTH) and (MONTH) of 2024. They stated they usually tried to reorder Resident #1's Nuplazid before the 14-day mark but could not recall times when it was ordered late. Resident #1 was on the medication because they hallucinated, had behaviors and would place themself on the floor. They stated that Resident #1 had only been on it a short time before they left as unit manager, but their behaviors improved in that time frame. They stated anytime there was a lapse in a resident receiving any medication that was ordered daily, the facility should update the physician. It was important to reorder medications, especially antipsychotics so that they could be administered as ordered. During an interview on 3/4/25 at 2:49 PM, the Consultant Pharmacist stated when a person abruptly stopped taking Nuplazid behaviors and hallucinations could emerge. They stated Nuplazid was an important medication for Resident #1, and they should've received it as ordered. They stated they do a monthly review of antipsychotics but nurses in the facility were responsible for monitoring any issues in the interim. During an interview on 3/5/25 at 11:34 | Plan of Correction: ApprovedMarch 27, 2025 1. Resident #1 was assessed for 5 consecutive days and reviewed with the Medical Director and determined to have no current negative outcomes. Care plan was reviewed and in concert with the residents needs. Medication error report was completed and shared with the IDT member, physician, pharm consultant and dispensing pharmacy. Consultant ordering Psychiatrist was updated on the omission and a follow up visit was provided/pending. 2. All residents experiencing changes in conditions or falls have the potential to be effected by this deficient practice. The DON conducted a review of all residents currently in the facility experiencing changes in condition, medications not being administered as ordered and falls to determine physician notifications were completed. No other deficiencies were found. 3. Measures that were put in place to ensure the deficient practice does not recur. The Unit Manager was educated on the policies titled Medication/Treatment Administration Documentation and Change in Resident's Condition, Medication/Treatment or status. The DON will conduct an audit of 10 residents a week with falls and/or a change in medical conditions to determine notification to the physician until 100% compliance for 4 consecutive weeks is sustained included in the audit will be a review to determine that the medical provider was notified of missed medication doses. The policies were reviewed and no changes were necessary. All staff responsible for Medication Administration Documentation were educated on the policy titled Medication/Treatment Administration Documentation. All staff responsible for Physician notifications and family notifications regarding changes of care and resident condition were educated on the policy titled Change in Resident's Condition, Medication/Treatment or status. The facility reviewed all orders with 14 day renewals on the MAR / TAR and changed the orders to standing orders so the order will not fall off. The Pharmacy will send reminders if additional authorization is needed prior to filling the medication. 4. Results of the above will be provided to the Quality Improvement Committee on an on-going bases to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be immediately counseled. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 5. Corrective action will be completed by 05/18/ 2025. The Director of Nursing Services is responsible for implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 5, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (#NY 323) the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) met the needs of each resident. Specifically, for one (Resident #1) of three residents reviewed the facility did not ensure medications were acquired and administered in accordance with the physician's orders [REDACTED].#1 was not administered 20 doses of their antipsychotic medication. The finding is: The policy titled Ordering Medications/Treatments from Pharmacy, last revised 5/2023, documented medications and treatments would be obtained as prescribed by the prescribing practitioner for individual resident use. The policy titled Medication/Treatment Discrepancy/Error, last revised 3/2011, documented the purpose of the policy was to assure proper medication/treatment administration and compliance with the legal requirements of medication administration and to report all errors in medication administration and documentation. The attending Physicians shall be notified and the Consultant or Vendor Pharmacist and resulting orders carried out. A Medication Discrepancy/Error Report Form will be completed on all medication errors. 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) dated 1/24/24 documented Resident #1 was cognitively intact, understands, was usually understood, and received an antipsychotic. Review of comprehensive care plan dated 11/3/21 documented Resident #1 had history of falls and was known to intentionally place self on floor and crawl on their knees (2/24/23). The comprehensive care plan documented Resident #1 had history of periods of paranoid thoughts and expressions; seeing people/animals that aren't there; wandering into others' rooms, and an overnight mental health stay at hospital on 4/4/ 23. Interventions included to monitor therapeutic effects and side effects and report to provider as needed. The Psychiatry note dated 1/24/24 completed by the Neurologist/Psychiatrist documented Resident #1 was to start Nuplazid (antipsychotic medication used to treat hallucinations) 10 milligrams for continued behaviors of crawling on floor, refusing and fighting with staff when attempting to provide care. A nursing progress note dated 1/24/24 at 3:15 PM Licensed Practical Nurse Unit Manager #1 documented Resident #1 was seen by the Psychiatrist and had a new order for Nuplazid 10 milligrams once daily at bedtime. The note documented they were awaiting approval from the insurance company. On 1/31/24 at 4:32 PM it was documented the order for Nuplazid was approved for 14 days at a time. The Order Summary Report dated 3/4/25 documented a physician's orders [REDACTED]. 24. The order was to be renewed and continued every 14 days. Review of the Medication Administration Records dated 1/1/24 to 5/31/24 revealed there was no order in place for the Nuplazid 10 milligrams from 3/28/24 to 4/11/24 and 4/26/24 to 4/31/ 24. The medication was not administered on those dates. Review of the 72 Hour Summary dated 3/28/24 to 4/11/24 revealed there was no documented evidence Resident #1's Nuplazid was reordered or administered. The facility was unable to provide the 72 Hour Summary for 4/26/24 to 4/31/ 24. A nursing progress note dated 4/11/24 at 2:52 PM completed by Licensed Practical Nurse Unit Manager #1 revealed Resident #1 was examined for their monthly physician visit, and it was noted that Nuplazid 10 milligrams daily was reordered to start every night. In a follow up note on 4/11/24 at 2:57 PM, they documented Nuplazid must be reordered every 14 days per insurance, reorder on 4/12/ 24. A physician progress notes [REDACTED].#1 documented Resident #1's psychiatry consult from 3/6/24 was appreciated and recommendations followed. However, the patient's Nuplazid fell off after two weeks. Will resume. Review of Resident #1 chart dated 3/28/24 to 5/1/24 revealed there was no documented evidence that medication error reports were completed regarding the 20 missed doses of Nuplazid. During an interview on 3/4/25 at 1:26 PM, Licensed Practical Nurse Unit Manager #2 stated they were not aware they had to physically write a new order every 14 days for Resident #1's Nuplazid. They thought it was like all other medications where you just click the reorder button. In mid-April the physician noted the medication needed to be reordered, so they wrote a new order at that time. Resident #1 had some behaviors during that time where they were refusing their medications and hands on care and had some episodes of placing themselves on the floor. Licensed Practical Nurse Unit Manager #2 stated they then realized the medication was not administered for a couple days again at the end of (MONTH) and put the order in on 5/1/ 24. At that time they stated a reminder was added to their calendar to ensure it did not happen again. Licensed Practical Nurse Unit Manager #2 stated Nuplazid was very important for Resident #1's health status. Someone taking an antipsychotic should never stop it abruptly. Any time there was a lapse in a medication being given, the physician should be notified. If the doctor would have been updated about the reorder not being done, then they could have reordered it, and the resident wouldn't have gone without it for that long of a period. During an interview on 3/4/25 at 2:02 PM, the Neurologist/Psychiatrist stated Nuplazid was an important medication for Resident #1, to maintain their current mental health status. Resident #1 became dysfunctional without the medication. Resident #1 should have received the medication as ordered, once a day. The Neurologist/Psychiatrist stated the facility should have followed their protocols and reordered the medication according to the order. During an interview on 3/4/25 at 2:16 PM, the Assistant Director of Nursing (interim Director of Nursing) stated Nuplazid was a specific medication that required a new prescription to be written and signed by the physician every 14 days and needed to be entered into the computer system each time. There was a period when they were between unit managers on Resident #1's unit and this incident occurred during that time frame. The Assistant Director of Nursing (interim Director of Nursing) stated the cart nurses were responsible for alerting the unit managers when the medication was running low so that a new order could be written. Nuplazid was ordered by the resident's Neurologist/Psychiatrist and should have been followed per their recommendations. When a resident had a missed dose of any medication the provider should be made aware, especially an antipsychotic. The resident should be assessed for any adverse effects. If anyone goes without their antipsychotic for any amount of time, there were risks to the resident. During an interview on 3/4/25 at 2:45 PM, Licensed Practical Nurse Unit Manager #1 (former UM) stated the insurance company would only allow 2 weeks' worth of Nuplazid at a time, and they had to keep reordering it before it would run out. If there was a lapse in receiving a medication, the facility would have to update the physician. During an interview on 3/4/25 at 2:49 AM, the Consultant Pharmacist stated when a person abruptly stops taking Nuplazid behaviors and hallucinations could emerge. Resident #1 should have received it as ordered. They stated they stated they do a monthly review of antipsychotics but do not have any sort of role in the process or monitoring of reordering medications. The review and ordering process was typically done by nursing. If it was an insurance issue the nursing staff should ensure they were reordering the medication according to the time frame provided by the insurance company to ensure there was an adequate supply av | Plan of Correction: ApprovedMarch 27, 2025 1. Resident #1 had an immediate review of his Medication Administration Record [REDACTED]. Resident was assessed and monitored for 5 consecutive days to monitor for adverse effects. None were noted. MD was notified regarding medication omission. Medication error report was completed and shared with the IDT member, pharm consultant and dispensing pharmacy. Residents care plan was reviewed and in concert with residents current needs. A reminder was added to the DON, ADON and Unit Managers calendars every 14 days for Res #1's Nuplazid renewal. An additional order was entered to reorder the medication every 14 days to trigger the medication nurse to ensure medication is reordered timely. 2. All residents on 14 day renewal medications, with medications that have special medication ordering needs or medications requiring a new script have the potential to be effected by this deficient practice. The facility reviewed all other residents to ensure there were no other special medication ordering needs. None were identified. The DON conducted a full house audit of all residents on medications requiring a new script or preauthorization and no other issues were found. The facility changed all orders with 14 day renewals on the MAR / TAR to be entered as standing orders so that a new script is not required each time so this problem does not recur. The pharmacy will notify the facility if a preauthorization is needed. 3. The Unit Manager was educated on the Ordering Medications/Treatments from Pharmacy policy and the Medication/Treatment Discrepancy/Error policy. -The policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error were reviewed and no changes were necessary. 4. Measures that were put in place to assure the deficient practice does not recur: - All staff responsible for Medication / Treatment Administration were educated on the policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error - The DON will conduct weekly audits of the resident population with 14 day renewals to ensure orders are present. All current and new 14 day renewal orders will be audited weekly until 100% compliance is sustained x 4 weeks If 100% compliance is not found, the staff involved will be counseled immediately. 5- Results of the above will be provided to the Quality Improvement Committee on an on-going bases to monitor compliance. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 5. The Director of Nursing will be responsible for monitoring compliance of the corrective plan with the facility administrator having overall responsibility for the conduct of the plan. Corrective action will be completed by 05/18/ 2025. |