Far Rockaway Nursing Home

Based on interviews and record reviews during an abbreviated survey, the facility did not ensure that each resident's drug regimen was free of any significant medication error. Specifically one (Resident #1) of three residents reviewed for medications had a written physician's order for the medication Depakene (Valproic Acid- for mood disorder) liquid 250 milligrams (mg) by mouth (po) am & (and) hs (at bedtime). Contrary to the physician's order, Resident #1 was administered the medication Depakene 250 mg po every 8 hours for a total of 80 doses.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Complaint ID number: NY00103578

The finding is:

Resident #1 was 66 years old and admitted to the facility with diagnoses including dementia due to alcoholic abuse and mood disorder.

The facility's policy and procedure for Drug Administration and Order from physicians dated 2/2005 documented that it is the responsibility of the nurse who picks up the order to enter the order in the facility's drug administration recording system. The nurse will then sign and date the physician order sheet, as having picked up the order, two nurses must review and cosign the order for accuracy; if order is not clear to nurse the physician shall be contacted for clarification.

The Minimum Data Set (MDS) assessment dated 5/15/11 documented the resident's cognitive status as moderately impaired.

The Physician's Interim Order dated 6/7/11 documented Depakene liquid 250 mg po am & hs. The order was cosigned by two additional nurses.

The Medication Administration Record (MAR) dated 6/7/11 documented Depakene liquid 250mg po every 8 hours (6 AM, 2 PM, 10 PM) 6/7/11-7/3/11.
The MAR documented that a total of 80 doses of the medication (Valproic Acid) were administered to the resident.

The facility investigation report dated 7/13/11 documented Resident #1's Depakene liquid 250 mg po frequency was wrong; resident was receiving Depakene liquid 250 mg q (every) 8 hours instead of q am and hs since 6/7/11.

Interview with Assistant Director of Nursing (ADON) on 7/15/11 at 10:40 AM, she stated that she could not recall the exact date or conversation but the Registered Nurse (RN) supervisor told her that the medication Depakene was transcribed incorrectly. The ADON stated that she read the physician's order, MAR, actual medication bottle and consult sheet. She added, if you looked quickly at the physician's order it did appear that the medication was ordered every 8 hours (ordered q am and hs). The ADON stated that RN supervisor called the physicians about the error and completed the medication error report.

Interview with RN supervisor on 7/15/11 at 11:10 AM, she stated that the psychiatrist evaluated Resident #1 on 6/7/11 and wrote the order for Depakene on the physician's order sheet. The RN supervisor read the order as every 8 hours, called the Attending physician and made him aware. She received a telephone order for the medication, transcribed the order as every 8 hours and faxed it to the pharmacy. The RN supervisor stated that on 7/4/11, LPN #8 was reviewing monthly orders and noticed a discrepancy for Depakene. LPN #8 made the RN supervisor aware that the medication was not supposed to be q 8 hours but am and hs. The RN supervisor reviewed the original physician's order and recognized the "and" was not an 8. She notified the physicians of the error. She added that the original orders were verified by 2 other nurses.

Interview with the Director of Nursing (DON) on 7/15/11 at 11:48 AM, she stated that it was an understandable mistake; "if you read the order, it appeared to be q 8 hours, the "and" looked like an 8". She stated that 3 nurses are to verify physician orders . If one of the nurses note any discrepancy, the supervisor or physician should be notified. During a subsequent interview with the DON at 1:35 PM, she stated that she spoke with the Medical Director and made him aware that the psychiatrist handwriting was not clear, but she was not aware of what intervention was taken related to the handwriting.

Interview with 7 AM- 3 PM LPN charge nurse #2 on 7/15/11 at 12:10 PM, she stated that on 6/7/11 she verified Resident #1's physician order; the order and MAR matched. She did not observe any discrepancy. LPN charge nurse #2 further stated that she was in-service and knows to clarify any discrepancy but she did not observe any discrepancy when she reviewed the Depakene order on 6/7/11.

Interview with the Attending Physician/Medical Director on 7/15/11 at 12:11 PM, he stated that the resident received "more Depakote (Depakene) that what was wanted." The physician stated that he was notified by the DON and her assistant and was told that the psychiatrist's handwriting was illegible. He added that a memo was sent to the facility's Attending physicians this morning; stating their orders have to written clearly. The physician stated that he would speak to the psychiatrist this evening to discuss the orders written.

Telephone Interview with the Psychiatrist on 7/18/11 at 3 PM, he stated that he wrote an order for Depakene to be given twice a day (am and hs). He was notified by a facility staff member that an error was made and Resident #1 was given the medication three times per day. The psychiatrist stated that there was no harm to Resident #1.

Telephone Interview with 3 PM-11 PM LPN charge nurse #7 on 7/19/11 at 1:18 PM, she stated that she verified Resident #1's medication order on 6/7/11. She looked at the original order and compared it against the MAR but did not notice any discrepancies. LPN charge nurse #7 stated that she read the Depakene order as q 8 hours and that is what she verified. She added that when she administered the medication she checked the medication label and the MAR. LPN charge nurse #7 stated that she received counseling regarding the medication error.

Telephone interview with 11 PM-7 AM LPN charge nurse #8 on 7/19/11 at 4:08 PM, she stated that on 7/3/11 going into 7/4/11 she was preparing Resident #1's monthly orders for review. The process includes reviewing all orders written within the month. LPN charge nurse #8 stated that she read the order for Depakene q am and hs, but noted a discrepancy on the MAR. The MAR documented the frequency as every 8 hours. LPN charge nurse #8 stated she made the 7 AM-3 PM RN supervisor aware that there was an error with the medication; that it was q 8 hours instead of am and hs. The RN supervisor handled the situation.

415.12 (m)(2)

Based on record review and staff interviews during the abbreviated survey, the facility did not ensure that the use of Outside Resources met professional standards. Specifically, one (Resident #1) of three residents' physician prescribed the medication Depakene (Valproic Acid- for mood disorder) liquid 250 milligrams (mg) by mouth (po) am & (and) hs (at bedtime).The pharmacy dispensed Valproic Acid liquid 250 mg po every 8 hours. Subsequently, Resident #1 was administered a total of 80 doses of the medication
(Valproic Acid).
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Complaint ID number: NY00103578

The finding is:

Resident #1 was 66 years old and admitted to the facility with diagnoses including dementia due to alcoholic abuse and mood disorder.

The Pharmacy services agreement dated 1/1/06 documented that the pharmacy will only supply approved drugs, intravenous solutions, biologicals and supplies in compliance with applicable local, state, and federal laws and regulations for residents and facility.

The Minimum Data Set (MDS) assessment dated 5/15/11 documented the resident's cognitive status as moderately impaired.

The Physician's Interim Order dated 6/7/11 documented Depakene liquid 250 mg po am & hs.

Review of the liquid medication bottle dispensed by the Pharmacy dated 6/30/11 documented Valproic Acid (Depakene) 250mg/5ml- 5ml (250mg) by mouth every 8 hours.

The Medication Administration Record (MAR) dated 6/7/11 documented Depakene liquid 250mg po every 8 hours (6 AM, 2 PM, 10 PM) 6/7/11-7/3/11.
The MAR documented that a total of 80 doses of the of the medication (Valproic Acid) were administered to the residents.

Telephone interview with the Director of Pharmacy (DOP) on 7/15/11 at 1 PM, she stated that Valproic Acid 250mg/5 ml every 8 hours was dispensed to the facility on 6/7/11 and 6/30/11. The DOP reviewed the original order dated 6/7/11 and noted a discrepancy; she stated that the original order read " Valproic acid 250 mg every am and hs". The "and" on the Physician's Order Form looked like an "8." She did not know how the error occurred and this was the first time that she became aware of the discrepancy. The facility did not contact the pharmacy in reference to the discrepancy.

Interview with the Director of Nursing (DON) on 7/15/11 at 1:35 PM, she stated that she did not make the pharmacy aware that the medication was dispensed incorrectly because it was the facility's error.

Telephone Interview with the Attending Physician/Medical Director on 7/18/11 at 12:11 PM, he stated that the resident received "more Depakote (Depakene) than what was wanted." The physician stated that he did not speak with the pharmacy and was unsure if anyone at the facility had done so.

Telephone Interview with the Psychiatrist on 7/18/11 at 3 PM, he stated that he wrote an order for Depakene to be given twice a day (am and hs). He was notified by a facility staff member that an error was made and Resident #1 was given the medication three times per day. The psychiatrist stated that there was no harm to Resident #1.

415.26(e)(i-iv)