Isabella Geriatric Center Inc
Deficiency Details, Complaint Survey, August 16, 2011
Regional Office: MARO--New York City Area
F333 483.25(m)(2): RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS
Severity: Actual Harm
Corrected Date: September 15, 2011
The facility must ensure that residents are free of any significant medication errors.
Citation date: August 16, 2011
Based on observation, interview and record review during an abbreviated survey, the facility did not ensure that residents were free of significant medication errors. Specifically, Resident #2 received a total of 7 medications that were prescribed to Resident #1. Resident #2 was subsequently transferred to the hospital for lethargy and unresponsiveness. The resident was monitored for 24 hours in the hospital and treated for altered mental status and dehydration. Additionally, staff did not follow accepted professional standards of practice during medication administration. Staff was observed leaving medications unattended on the medication cart and pre-pouring medications.
This resulted in actual harm that is not Immediate Jeopardy as evidenced by 1 out of 9 sampled residents (Resident # 2). For Residents #1, 3 and 4 this resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy.
NY000095273 and NY00099163
The findings are:
Resident #1 was admitted to the facility on 6/23/08. Her diagnoses included Cerebrovascular Accident, Right Hemiplegia, Diabetes Mellitus, Hypertension, and Major Depression with Psychotic Features.
The Minimum Data Set (MDS) Assessment 3.0 dated 3/4/11 identified that the resident had moderate impairment in cognitive skills for daily decision making. The resident required extensive assistance with Activities of Daily Living (ADL's).
According to the Medication Administration Record, dated 3/23/11-4/22/11 the resident's 9:00AM medications included Ativan (anti-anxiety) 1 milligram (mg) tablet, Citalopram HBR (anti-depressant) 40mg tablet, Gabapentin (anti-convulsant) 100mg, Leveitracetam (anti-convulsant)1000mg tablet, Phenytoin (anti-convulsant)125mg/5 milliliter (ml) suspension, Plavix (anti-platelet) 75mg and Seroquel (anti-psychotic) 100mg tablet.
A review of the Medication/Treatment Error Form, dated 3/23/11 stated that at 9:47AM Resident #2 received medications that were intended for Resident #1. Licensed Practical Nurse (LPN) #1 gave the medications to the Certified Nurse's Aide (CNA) to administer to Resident #1. The CNA administered the medications to Resident #2.
Resident #2 was admitted to the facility on 11/14/09 with diagnoses of Dementia, Diabetes Mellitus, Cerebrovascular Accident, Chronic Kidney Disease, Hypertension, Degenerative Joint Disease and Pneumonia.
The MDS 3.0 dated 3/4/11 identified that the resident had moderate impairment in cognitive skills for daily decision making. The resident required assistance in performing all ADL's.
The Physician's Notes dated on 3/23/11 documented that resident was noted with lethargy; vital signs were taken and the physician ordered to hold all medications dated 3/23/11. A second Physician's Note dated 3/23/11 stated that the resident was not arousable and ordered transfer to the hospital.
The Transfer Notice, dated 3/23/11 stated that the resident was sent to the hospital due to lethargy and unresponsiveness secondary to a medication error.
The nursing notes, dated 3/23/11 stated that at 10:45AM LPN #1 reported that she gave the wrong medication to the resident with the CNA's help. At 11:30AM Resident #2 was assessed and noted to be drowsy, but opened her eyes when her name was called. The MD was notified and ordered to hold all medications. At 12:50 PM the resident was noted as unresponsive to verbal stimuli and responsive to painful stimuli. The MD ordered intravenous (IV) fluid with normal saline solution. A nursing note dated 1:05PM stated that the IV fluids were started. The resident was transferred to the hospital at 2:40PM.
On 3/23/11 at 10:00AM a telephone interview was conducted with the CNA. She stated that she saw that the LPN #1 was having a hard time administering medication to Resident #1. The LPN asked her for assistance with the medication administration. The CNA stated that the LPN gave her medications and asked her to administer them to Resident #2. She stated that she administered the medications to Resident # 2.
On 3/25/11 at 1:48PM an interview was conducted with the LPN #1. The LPN stated that Resident #1 refused to take medication that day and the CNA offered to help. She stated that she gave the medication to the CNA and stated to please give it to the resident (Resident #1). The CNA gave it to the wrong resident (Resident #2). The LPN stated that later she realized that they made a mistake and reported it immediately to the supervisor. The LPN stated " it was my mistake I should not have allowed a CNA to administer medication to that resident. "
Subsequently, Resident #2 was transferred to the hospital for lethargy and unresponsiveness.
Resident #3 was admitted on 2/16/11 with diagnoses including Right Transmetatarsal Amputation with Gangrene of 2nd and 3rd right toe, Diabetes Mellitus, Chronic Systolic Heart Failure and Osteoarthritis.
The MDS 3.0 documented that resident has impaired cognitive skills for daily decision making. The resident required limited to extensive assistance in performing ADL'S.
The Physician's Order dated 3/15/11 documented that resident was prescribed Aspirin EC 81mg tablet, Carvedilol, Hydralazine, Ferrous Sulfate, Isosorbide at 9AM.
On 4/4/11 at 10:00AM LPN #2 was observed during medication administration for Resident #3. The LPN was observed pre-pouring liquid medication for 6 residents, including Resident # 3's medication. The LPN was also observed leaving the medication cart unattended with all the pre-poured medications sitting on top of the cart.
On 4/4/11 at 11:58AM LPN #2 was interviewed. The LPN stated that she pre-poured the medications because there are so many residents and all of these residents were on pro stat medications. LPN #2 stated " yes I am well aware of medication administration policy, but if we follow those rules we will never finish giving medications. "
Resident # 4 was admitted to the facility on 3/10/11 with diagnoses of Diabetes Mellitus, Hypothyroidism, Cellulitis, Hypertension, Severe Chronic Lower Extremity Lymph Edema, Chronic Heart Failure, Chronic Kidney Disorder and Dementia.
The Integrated Admission Assessment, dated 3/10/11 identified that the resident was alert, but not oriented to person, place or time.
The Physician Orders, dated 4/8/11 documented that the resident was prescribed Novolog R Insulin 100 units/ml vial with sliding scale coverage at 11:45AM for Diabetes.
On 4/4/11 at 11:55AM during an observation of the medication administration for Resident #4, LPN #3 was observed leaving the medication cart open and unattended. The top of the cart contained medications and 4 vials of Novolin R Insulin for Resident #4 and three other residents.
On 4/4/11 at 12:01PM an interview was conducted with LPN #3. LPN #3 stated " I prepared all of this on the cart and I should not leave it unattended. "