Split Rock Rehabilitation and Health Care Center
Deficiency Details, Complaint Survey, April 10, 2012
Regional Office: MARO--New York City Area
F333 483.25(m)(2): RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS
Severity: Potential for more than Minimal Harm
Corrected Date: June 5, 2012
The facility must ensure that residents are free of any significant medication errors.
Citation date: April 10, 2012
Based on staff interview and record review during an abbreviated survey, the facility did not ensure that a resident was free of a significant medication error. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, Resident #1's medication order for Cefepime 1 gram intravenous via Mediport was not given in accordance with the physician's order for 2 doses.
This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.
Complaint ID # NY00111766
The findings include:
Resident #1 was a 51 year old female admitted on 01/27/12 and she was discharged to the hospital on 01/30/12. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD) with Exacerbation, Congestive Heart Failure (CHF), Pulmonary Hypertension, Chronic Low Back Pain and Morbid Obesity. The Nursing Admission Assessment, dated 1/27/12 documented that the resident was alert and oriented.
A review of the Hospital Transfer Form dated 01/27/12 indicated that the resident required Cefepime Hydrochloride 2 grams intravenous (IV) every 12 hours for 6 days to be given via Mediport.
A review of the Medication Administration Record (MAR) revealed Cefepime 2gm IV was not given on 1/27/12 at 6:00 PM and 1/28/12 at 6:00 AM (missed 2 doses).
A review of nurse's note dated 1/28/12 at 3:00PM documented that the Access Nurse (vendor nurse from the pharmacy to access an IV) was called and came in to access the IV port in the right upper chest for IV antibiotic to be given at 6:00PM.
A review of the nurse's note dated 01/30/12 revealed that the resident was transferred to the hospital for leaking Mediport and complaint of pain and discomfort to the Mediport site.
The facility policy and procedure titled " Intravenous Therapy " stated that it is the policy of the facility to provide intravenous therapy , per the physician order. The policy identified IV therapy types including implanted ports, such as Mediport.
An interview with the Registered Nurse Supervisor (RNS) #1 was conducted on 2/7/12 at 11:30 AM. The RNS was the admitting nurse who worked the night of Resident #1's admission. The RNS stated that on the night of admission, when she identified that the resident required medications via the Mediport, she offered to have a peripheral line inserted for IV antibiotic use, but the resident declined and refused to be sent back to the hospital. The RNS stated that she is not familiar with accessing Mediport even though she has an IV certification.
An interview with RNS #2 was conducted on 2/7/12 at 10:00 AM, she worked on 11:00PM- 7:00AM on 1/28/12. She stated that she is not familiar with Mediport. She stated that she waited for the Access IV nurse to access the port in order to start with IV antibiotic therapy.
An interview with the RNS #3 was conducted on 3/12/12 at 1:00PM, who worked 7:00AM-3:00PM on 1/28/12. She stated that she notified the MD of Resident #1's missed antibiotic and that her IV port could not be accessed at the facility. The MD ordered to send the resident to the hospital. RNS #3 stated that she called the Access IV nurse and was told not to send resident to the hospital because she would be in the facility to access the Mediport. RNS #3 stated that she has an IV certification but is not familiar with accessing Mediport.
An interview with the Director of Nursing (DON) was conducted on 2/3/12 at 3:00 PM. She stated that she reviewed the resident's admission and the hospital paperwork did not indicate IV antibiotic to be given via port. The DON stated that if known, they would have made arrangements for the Access IV Nurse to be available when the resident was admitted.