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Scope: Isolated
Severity: Actual harm has occurred
Citation date: December 16, 2024
Corrected date: February 11, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case # NY 837), the facility did not ensure residents were free from significant medication errors for 2 (Resident #s 1 and 2) of 3 residents reviewed. Specifically, the facility (1) did not ensure Residents #1 and #2 received their own medication as ordered when Resident #2 received Resident #1's antibiotic for 5 days from [DATE] through [DATE] for a total of 5 doses, and (2) did not ensure the electronic medical record was accurate for Resident #s 1 and 2 for those 5 days. This is evidenced by: The Policy and Procedure titled physician's orders [REDACTED]. It documented all new orders entered in the electronic medical record order portal by a licensed nurse must be confirmed by a second nurse. It documented the nurse would document in the progress notes and on the 24-hour report that the new order was received and entered. If the order was found to be entered inaccurately, the second nurse must immediately re-enter the order seeking clarification from the ordering physician if needed. The third nurse checking the order would follow the same sequence of steps indicated above for the nurse completing the second check. If the 11 PM to 7 AM nurse was a Per Diem/Agency nurse, the Shift Supervisor would ensure the policy was followed. The Policy and Procedure titled Medication Errors, reviewed on [DATE] and last reviewed on [DATE], documented it was the facility's policy to have systems in place to monitor any medication errors. The purpose of the policy was to ensure that all medication concerns were reported in a timely manner and actions were taken to prevent further concerns. Resident #1: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated [DATE], documented the resident could be understood and could understand with moderate impaired cognition for decisions of daily living. Resident #1's Comprehensive Care Plan for Acute Kidney Failure related to kidney disease acute kidney failure and [MEDICAL CONDITION] stage 1, initiated [DATE] and revised [DATE], documented a care plan goal that the resident would be free from infection. Care plan interventions documented to give medications as ordered by the physician. Resident #1's Comprehensive Care Plan for Infection of extended spectrum beta-lactamase (ESBL-an enzyme found in some bacteria that breaks down and destroys some commonly used antibiotics, making the drugs ineffective for treating infections) in the urine, initiated on [DATE], documented urinary tract infection and contact precautions were in place. Care plan goals documented the resident would be free from complications related to infection. Resident #2: Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident could be understood and could understand and cognitively intact. Resident #2's Comprehensive Care Plan for Fluid Overload or Potential Fluid Volume Overload related to end stage [MEDICAL CONDITIONS], and primary malignant neoplasm of prostate (cancer of prostate), last revised [DATE], documented a care plan intervention to administer medications as ordered. The Laboratory/Prescription Note dated [DATE] at 11:39 AM for Resident #1 by Registered Nurse Manager #1 documented the physician/Medical Doctor #2 was notified about Resident #1's test result being positive for extended spectrum beta-lactamase in the urine. The Sub-Acute Medical Doctor/Nurse Practitioner Follow-up for Resident #1 dated [DATE] at 12:15 PM by the physician/Medical Doctor #2 documented the reason for the visit was urinary tract infection. The resident complained of mild dysuria (discomfort associated with urination). The Assessment/Plan documented urinary tract infection and the urine culture showed Proteus and E. Coli (bacteria) with multiple resistances (to antibiotics). The plan was to treat the infection with Bactrim DS for 5 days. Review of the Order Summary Report for date range [DATE] to [DATE] for Resident #1 did not document an order dated [DATE] for Bactrim DS for urinary tract infection. Review of the Order Summary Report for date range [DATE] to [DATE] for Resident #2 documented an order dated [DATE] for Bactrim DS ,[DATE] milligram to be given; 1 tablet every 12 hours for urinary tract infection for 5 days. Review of the Medication Administration Record [REDACTED]. The Medication Error Details Report - Occurrence # 7 written by the Registered Nurse Manager #2 who was then Assistant Director of Nursing documented an error was detected on [DATE] at 8:00 AM. It documented Registered Nurse Manager #1 was responsible for error type, wrong resident. The medication as ordered and as administered documented Bactrim DS ,[DATE] milligram: twice a day for 5 days. The error cause documented transcribed to wrong resident and documented 5 doses were administered. The residents were not named in the report. The Nurse's Note for Resident #2 dated [DATE] at 8:55 AM written by Registered Nurse Manager #1 documented the physician #1 was made aware that they made a mistake by putting the order for Bactrim DS to Resident #2 instead of Resident #1, and that it was discontinued the morning of ,[DATE]/ 2021. It documented the physician #1 told Registered Manager #1 to let the resident know about this incident. The Nurse's Note for Resident #2 dated [DATE] at 9:46 AM written by Registered Nurse Manager #1 documented Resident #2 was made aware that they did not have a urinary tract infection and that they received antibiotics over the weekend by mistake. Resident #2 denied having adverse effects and no rash or swelling were noted. It documented the resident's vital signs were taken and were within normal limits. The Sub-Acute Medical Doctor/Nurse Practitioner Follow-up Note for Resident #2 dated [DATE] at 4:58 PM by the physician #1 documented they were asked to evaluate the resident. The resident was given antibiotics in error. The resident had no complaints and stated they were okay. Review of the Order Summary Report for Resident #1, date range [DATE] to [DATE], documented an order dated [DATE], for Bactrim DS ,[DATE] milligram to be given every 12 hours for 5 days for urinary tract infection. The Medication Administration Record [REDACTED]. Resident #1's Comprehensive Care Plan for Infection of extended spectrum beta-lactamase in the urine, documented a care plan intervention initiated on [DATE], to administer antibiotic as ordered by the physician; Bactrim DS 1 tablet twice daily for 5 days. The Follow up Report - Occ. # 7 dated [DATE] at 9:08 AM written by Registered Nurse Manager #2 who was then the Assistant Director of Nursing, documented the following conclusion: the interdisciplinary team met, and it was determined that the root cause was an order transcription error. Registered Nurse Manager #1 did not follow the facility's physician's orders [REDACTED]. A facility wide audit was performed on all medication orders initiated [DATE] to ,[DATE]/ 2021. The Information Technology department was asked to investigate if users could confirm their own orders. It was discovered that confirm all pharmacy orders was set to on, meaning that prior to this date the Registered Nurse role users could confirm their own pharmacy orders. The option was immediately set to off and confirmed that all other confirm own order types was set to off as well. It documented this would ensure that a second nurse would confirm all orders prior to activation. Re-education on the physician's orders [REDACTED].#1 and education to all facility nursing staff on this policy was initiated and was on-going. Administration, Quality Assurance, Nursing, and Medical Director met. The policy was reviewed and updated. The residents were not named in the report. The Medication Error Investigations [DATE] by Registered Nurse Manager #2 documented the following: -On [DATE], the physician/Medical Director #2 wrote an order for [REDACTED].#2's electronic medical record in error by Registered Nurse Manager #1 on the same date. The error was noted on [DATE] at 8:53 AM by the Registered Nurse Manager #1, who immediately reached out to the physician to discontinue the medication and re-prescribed for Resident # 1. The medication error included: Resident #2 received 5 doses of Bactrim DS from Friday [DATE] through Sunday evening ,[DATE]/ 2021. -Resident #1 was exhibiting symptoms of urinary symptoms on [DATE] and therefore urinalysis and culture (urine tests) were obtained for analysis at the laboratory. The culture report was finalized on [DATE] and reviewed by the physician/Medical Director (#2), who gave an order for [REDACTED]. - Physician #1 was notified and the medication for Resident #2 was discontinued and antibiotic therapy for Resident #1's urinary tract infection was initiated. - Representatives were notified. - Quality Assurance and Performance Improvement and the Interdisciplinary team met to discuss the incident and to determine the root cause and plan to prevent re-occurrence. It was determined that the Registered Nurse Manager #1 did not follow the facility's Physician order [REDACTED]. - A facility-wide audit was performed on all new medication orders initiated [DATE] through ,[DATE]/ 2021. - The Social Worker followed up with both residents and both were doing well at the time. - Staff were asked to closely monitor both residents. -The Physician order [REDACTED]. -The Registered Nurse Manager #1 did not follow the facility policy for Physician order [REDACTED]. Human Resources was directed to review their file and there were no negative findings in the manner of disciplinary actions or other adverse documentation. They were provided with one-on-one training and written up for the error. -On [DATE], the Information Technology Department was tasked with investigating why users could confirm their own orders. The findings into the role of Registered Nurse revealed that nurses could confirm their own orders as the setting was set to the ON position mistakenly. This was corrected and the option was set to OFF on [DATE] at 10:45 AM. With the OFF position now selected, nurses would no longer be able to confirm orders they put in the (electronic ordering system). -The Registered Nurse Educator was directed and had initiated a facility wide Inservice on MEDICATION ORDERS FOR [REDACTED]. -The facility's investigation was deemed complete; the necessary audits were complete; in-services were ongoing. Quality Assurance and Performance Improvement had put in place necessary safeguards to avoid recurrence of the medication error. There was no evidence of abuse, mistreatment, or neglect but would be reported to the Department of Health as it met the basic criteria for reportability. During an interview on [DATE] at 1:58 PM, the Director of Nursing #1 stated the Registered Nurse Manager #1 no longer worked at the facility. They stated they were not the Director of Nursing at the time of the incident. During an interview on [DATE] at 2:08 PM, the Administrator stated the facility acted immediately when the medication error was identified. They stated the interdisciplinary team, Quality Assurance Performance Improvement team, and Medical Director all worked together on the corrective actions and the nursing staff was educated immediately. During an interview on [DATE] at 2:10 PM, Registered Nurse Manager #2 stated they recalled the incident with the medication error. They stated the medication error was discovered by the Registered Nurse Manager #1 on ,[DATE]/ 2021. They stated the Registered Nurse Manager #1 was very upset when they reported the error to them. They stated the error was remedied immediately and stated they had called interdisciplinary team on [DATE], to resolve the problem. They stated there was a setting in the (electronic ordering system) that allowed the nurse to confirm their own orders and stated the Information Technology staff changed the setting so that it could not be done. They stated both residents were immediately assessed and there were no negative findings. They stated Resident #1 had a urinary tract infection and there were no adverse effects from the delay in treatment. They stated nursing staff was monitored both residents closely following the incident. During an interview on [DATE] at 2:50 PM, Director of Nursing #1 stated antibiotic medication should have been entered into the (electronic ordering system) for Resident #1 but was entered for Resident #2 in error. They stated the Registered Nurse Manager #1 made the error and was the one who discovered the error on ,[DATE]/ 2021. They stated the error was reported immediately. They stated corrective action began right away on [DATE], including education to the nurses on the facility's policies for ordering medication in the (electronic ordering system) and the need for a second nurse to review and verify the order. They stated on [DATE], the Information Technology staff identified and corrected the problem and Registered Nurse Manager #1 was provided with one-on-one training about the facility's policies for medication ordering. They stated the facility did their medication order audits and policy education on [DATE] and was in compliance with the regulation on ,[DATE]/ 2021. During an interview on [DATE] at 9:34 AM, the Registered Nurse Manager #1 stated they were interrupted when they were entering the physician order [REDACTED]. They stated Resident #2 received 5 doses of the medication. They stated they realized the error on [DATE], and immediately called the physician. They stated they then told Resident #2 about the error and assessed the resident. They stated they also assessed Resident #1 and there were no negative findings. They stated they were still in orientation at the time and was not familiar with the facility's policy for medication ordering and the need to have another nurse review and confirm the order. They stated the facility found a problem in the (electronic ordering system) that was corrected right away. They stated the facility provided house-wide education to all nurses about the policy and the need to have another nurse confirm the order. They stated they were responsible and accountable for the error and reported it to the Registered Nurse Manager #2 who was the previous Assistant Director of Nursing. During an interview on [DATE] at 9:40 AM, Director of Nursing #1 stated the facility had no medication transcription errors since [DATE], and had no medication errors that were reportable to the New York State Department of Health. Past Non-compliance- F760 Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -On [DATE], the facility identified a medication error, and the following corrective actions were taken immediately: -- The physician was notified and gave an order to discontinue the antibiotic medication for Resident #2 and initiate antibiotic medication for Resident # 1. -- Resident #s 1 and 2 were immediately assessed by the Registered Nurse with no negative findings and were later evaluated by the physician with no acute concerns. -- The interdisciplinary team met to discuss the incident and directed all nurses to review new orders/charts of residents. No additional non-compliance was noted. -- Quality Assurance and Performance Improvement was summoned by the Administrator, including the Medical Director to review the incident and directed a facility-wide audit of transcribed medication orders/charts of all residents. No additional non-compliance was noted. -- The Staff Educator was directed and completed education for all nurses on all shifts on the proper policy and procedure for obtaining medication orders. - On [DATE], the following corrective actions were taken: -- Resident #s 1 and 2 were re-assessed with [REDACTED]. -- Facility-wide audit was completed on medication orders/charts for all residents in the facility. -- The Medication Error policy and Order Entry policy were both reviewed and needed a revision to include a nurse cannot confirm and verify their own orders in the (electronic ordering system). -- Facility Information Technology staff fixed and corrected the self-confirm in the (electronic ordering system), to include the requirement noted above. This new requirement was consistent with the Quality Assurance Performance Improvement findings and interventions. -- The Social Worker followed up Resident #s 1 and 2 with no negative findings. Socioemotional care was provided to both residents. Social Worker to provide ongoing support when needed. -- Registered Nurse Manager (#1) received counseling for the medication error and was provided one-on-one training, including review of the facility's policies and procedures. - At the time of survey, there were no additional reportable significant medication errors identified. A randomly sampled in-house resident was reviewed during the survey; there were no findings identified with medication administration and/or significant medication errors. 10 NYCRR 415. 12(m)(2) | Plan of Correction: ApprovedJanuary 8, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DP(NAME) F689 1. Immediate Correction: 1) The facility respectfully states Resident # 1 expired on [DATE] while in the hospital. 2)On [DATE] CNA #1 was terminated from employment and the Agency was notified of the reason for termination. 3)On [DATE] the DNS provided LPN# one with education and counseling on the need to conduct a thorough Shift report for all staff and the need to adjust CNA assignment as needed. 4)On [DATE] Rehab assessed resident post fall and there were no changes. 5) On [DATE] the DNS provided education and counseling for CNA #2 on the need to provide residents at risk for falls and/or with impaired cognition constant supervision when seated on the toilet. 6) On [DATE] resident #2 was assessed by the Rehab Department for the need for any assistive device to use when using the toilet. CCP was updated to reflect current toileting needs and supervision required. Instructions were carried over to CNAAR. 7) On [DATE] the facility contracted with GNYHCFA to develop and implement a DP(NAME) and Directed Inservice. 8) On [DATE] the GNYHCFA QA Consultants convened the Facility QA Meeting to review causative factors, specific interventions, and systems to maintain compliance with ensuring that the environment is as free of accident hazards as possible and that each resident receives adequate supervision to prevent accidents. II. Identification of Others: 1)The facility respectfully states that all residents were potentially affected. 2) The DON /RNS will reassess all facility residents for fall risk. The RNS will review/revise Fall risk CCP and CNAAR for individualized safety interventions as indicated. 3) A list of all residents requiring substantial to maximum assistance with transfer to the toilet was generated by the MDS Coordinator from the medical record. 4)The DON, RNS and MDS Coordinator reviewed each resident to determine the supervision required when sitting on the toilet considering fall risk, cognition, and behaviors. The residents CCP will be updated and instructions carried over to CNAAR. Any identified issues will be addressed. III. Systemic Changes: 1) The DON and GNYHCFA Consultant reviewed and revised the Policy and Procedure for Fall Prevention. 2) The DON and GNYHCFA consultant reviewed and revised the Policy and Procedure for CNA Accountability /Assignments. 3) All Nursing Staff and Rehab staff will receive Education by GNYHCFA on ensuring that the environment is as free of accident hazards as possible and adequate supervision and assistance is provided to residents to ensure resident safety. Highlights of the Lesson Plan include: ???All residents are assessed for Falls Risk on admission, readmission and quarterly and as needed. ???Any resident at High risk for Falls will be placed on the Falling Star identifier program with a green star in Electronic Medical Record (EMR), on Resident door and assistive mobility device if indicated. ???Any resident requiring physical assistance getting on/off toilet and/or with cognitive impairment cannot be left unattended in the bathroom. ???The joint responsibility of Rehab and Nursing to determine the amount of staff assistance required for all ADL's. ???The responsibility of the RNS to clearly communicate and document on the CNAAR/CCP the assistance needed for resident safety. ???The responsibility of the RNS to conduct Unit Rounds to supervise direct care staff for care provided to residents. ???The responsibility of the licensed unit nurse to complete assignments for CNAs and print from EMR a current list of residents requiring Mechanical lift with two persons and provide Shift Report to all CNAs. ???The responsibility of each CNA to identify the transfer status of their assigned residents and the steps to take to perform task. ???The steps the Nursing Assistant needs to take if he/she feels the directives for Residents care needs should be reviewed by the RNS/ IDT. ???The responsibility of all Nursing Staff to be aware of each resident's need for assistance and supervision as documented in the resident's CCP/CNAAR to prevent accidents. IV. Quality Assurance: 1) The GNYHCFA Consultant in conjunction with the DON developed an audit tool to monitor the facility's compliance with: A) Ensuring that each resident is provided with adequate supervision and assistance to ensure Resident safety while assisting residents with toileting and transferring care needs. B) Ensuring that all residents at high risk for falls will be identified and individualized interventions will be communicated to Direct Care staff 2) Audits will be done by the RNS on five randomly selected residents, and five randomly selected staff members on each unit on random shifts weekly x 4 weeks followed by monthly x 6 months. 3)Findings from the audits that require corrective actions will immediately be rectified and brought to the Morning QA Meeting for review. 4)Findings will be reviewed during the Quarterly QA Meeting to ensure sustainability. V. Person Responsible for this FTag: Director of Nursing |