Rosewood Rehabilitation and Nursing Center

Deficiency Details, Complaint Survey, May 26, 2010

PFI: 3920
Regional Office: Capital District Regional Office

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F309 483.25: PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING

Scope: Widespread

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: June 30, 2010

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

Citation date: May 26, 2010

Based on medical record reviews and staff interviews during a complaint investigation (Case #NY00085770), it was determined that the facility failed to provide necessary care and services that meet acceptable standards of clinical practice for 31 (Residents #s- 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18,19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31) of 78 residents reviewed. Specifically, the facility failed to implement a system to ensure that physician ordered medications were given to residents as ordered, failed to ensure that the pharmacy was made aware of medications that were not available, failed to notify the physician that medications were not available from the pharmacy for up to five days and failed to investigate missing medications. This resulted in Immediate Jeopardy to resident's health and safety and Substandard Quality of Care for residents . This was evidenced by the following:

1. Resident #11
The resident was admitted to the facility on 2/9/10 with diagnosis of a right oral cavity tumor. The Minimum Data Set (MDS) dated 5/5/10 assessed the resident to have intact cognition and memory.

The physician's orders dated 4/29/10 documented an order for Diflucan Suspension 50 milligram(mg)/5 milliliter (ml) daily (used to treat fungal infections), please give 10 ml per tube (p.t.) daily.

The Medication Administration Record (MAR) for the period of 4/1/10 through 4/30/10 documented Diflucan Suspension 50 mg/5 ml. Give p.t. daily at 8:00 am. The MAR was document with an "x" on 4/29/10 and a blank entry on 4/30/10. The Pain Medication, Medication and Hold notes section of the MAR did not include an entry for 4/29/10 or 4/30/10.

The MAR for the period of 5/1/10 through 5/31/10 documented Diflucan Suspension 50 mg/5 ml. Give p. t. daily at 8:00 am. The MAR dated 5/4/10 documented a time change for Diflucan to 7:30 pm. The MAR documented a circled entry on 5/1/10, 5/3/10 and 5/4/10 and a blank entry on 5/2/10. The MAR dated 5/10/10 had a circled entry and a note, "N/A ( not available) Nursing Supervisor aware." The Pain Medication, Medication and Hold Notes section of the MAR did not include entries for 5/1, 5/2, 5/3, or 5/4/10.

Nurse's notes for the period of 4/29/10 through 5/4/10 did not document a note related to Diflucan administration.

The 24-hour Tracking Sheet dated 5/3/10 documented a note, unsigned at 1:15 pm, "spoke with...pharmacy will send...Diflucan"

The facility policy and procedure titled, "Medication Administration" dated 4/09, section AA. documented, "if a dose of regularly scheduled medication is withheld, refused or given at a time other than the scheduled time (for example, if the resident is not in the facility at the scheduled dose time, or a started dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initiated and circled. An explanatory note is on the reverse side of the record provided for PRN documentation. If two consecutive drops of a vital medication are withheld or refused, the physician is notified."

The undated pharmacy policy titled, Facility Admission/Readmission Physician Order Form documented that upon an admission or readmission, a copy of the form was to be completed by the resident's physician or nurse and immediately faxed to the pharmacy. The second copy of the form should be forwarded to the pharmacy via the delivery person. The medication is filled with a 30-day supply, unless otherwise indicated, and sent to the facility with the next scheduled delivery.

The undated pharmacy policy titled, Physician's Monthly Order Form, documented that once the order is signed by the physician, immediately fax the orders to the pharmacy. Stamp or mark the order as "FAXED". After the order is faxed, return the second copy to the pharmacy via delivery person. All medications due, will be filled with a 30 day supply and returned to facility within 24 hours.

The undated pharmacy policy titled, "Demand/Re-order Medication Procedure, documented that demand items should be checked with each med pass, to identify medications which are running low and need to be re-ordered and to ensure medications will be available at all times. For items needed before the next monthly delivery was due, check the re-order date on the medication label, peel and affix label to the re-order sheet and fax to pharmacy, on the date indicated. Immediately fax the form to the pharmacy. Stamp or mark the form as "FAXED." After faxing, forward the original form to the pharmacy via the driver. Medication orders will be filled and returned to the facility within 24-48 hours. Please note the following medication will NOT be filled from the demand re-order form: Medications that are too soon to refill. Please use the "EARLY REFILL FORM" to re-order items needed prior to the re-order date indicated on the label. Please indicate the reason for the early refill.

During an interview with Licensed Practical Nurse (LPN) #1 on 5/20/10 at 9:30 am, LPN #1 stated that she had a lot of problems with medications not being available from pharmacy when needed. LPN #1 stated that as medication was needed, the medication label was peeled off, affixed to a refill form and faxed to the pharmacy. LPN #1 stated that when she realizes that a medication is not available or is running critically low and she knows she has placed an order, she informs the Registered Nurse Manager (RNM) and will sometimes contact the pharmacy by phone. LPN #1 stated that representatives from the pharmacy have often told her they didn't receive the fax and had no record of the order and that was the reason that medications were not delivered. LPN #1 stated that when this happens, she refaxed the order. LPN #1 stated that if an order was placed before the refill due date, the order would not be filled and must be ordered on the date of renewal. Ordering on the date of renewal, did not always ensure that a medication was available when needed.

During an interview with LPN #1 on 5/20/10 at 1:30 pm, LPN #1 stated that on 5/3/10 while passing morning medications, she did not have Diflucan available for Resident #11. LPN #1 stated that she informed the RNM and continued to pass medication and at 1:15 pm contacted the pharmacy to follow-up on an anticipated delivery time for a list of medications, including Diflucan and made an entry to the 24-hour Tracking Sheet.

During an interview with RNM #1 on 5/20/10 at 1:45 pm, she stated that circled, blank or entries marked with an "x" indicated that the medication ordered was not given to the resident and that a corresponding note should be made in the Pain Medication, Medication and Hold Notes section of the MAR. RNM #1 stated on 4/29/10 she received an order for Diflucan for Resident #11, transcribed the order to an interim physician's order form and faxed the interim physician's order form to the pharmacy and made a notation of , "faxed 4/29/10" on the order form. RNM stated that she placed the order in the resident's medical record, turned the colored dial on the side of the binder to red (to indicate a new order was awaiting signature by the physician) and placed the record on the record cart. RNM #1 stated that LPN #1 informed her on the morning of 5/3/10 that the resident had not received Diflucan from 4/29/10 through 5/3/10 and that the medication was not available. RNM #1 stated that she contacted the pharmacy and was informed that they did not receive the faxed order she was inquiring about. RNM #1 stated that she pulled the interim physician's order form from the resident's medical record and re-faxed it. When asked to review the MAR to identify when the first dose of Diflucan was administered to the resident, RNM #1 stated according to the MAR, the first dose was administered at 7:30 pm on 5/4/10, approximately 5 days after the order was written and more than 24 hours after the order was re-faxed to the pharmacy. When asked if she notified anyone that Resident #11 did not receive medication prescribed by the resident's physician, RNM #1 stated no, she did not notify anyone. When asked if the physician was notified that the Diflucan was not administered per the physician's order, RNM #1 stated, "no he was not, should he?"

During an interview with the RN Supervisor, who generally worked the 3:00 pm-11:00 pm shift, on 5/20/10 at 4:45 pm, stated that circled, blank or entries marked with an "x" indicated that the medication ordered was not given to the resident and that a corresponding note should be made in the Pain Medication, Medication and Hold Notes section of the MAR to document the reason the medication was not given. The RN Supervisor stated on the evening of 5/10/10 she was informed by LPN #2, Diflucan was not available. The RN Supervisor stated that she called the pharmacy and spoke with a pharmacist and informed the pharmacist of the need for Diflucan for the resident and then faxed an order. The RN Supervisor stated she then placed the order in the bin located in the main office for MD signatures and was not sure what happened to the order from after she placed in the folder. The RN Supervisor stated that the Diflucan was not available when she ended her shift on 5/10/10, however, upon review of the MAR she observed a entry on 5/11/10 at 1:00 am, to the Pain Medication, Medication and Hold Notes section that documented, "Diflucan in from pharmacy and given". The RN Supervisor stated that she verbally reports problems with pharmacy delivery and unavailable medications to the Director of Nursing (DON).

During an interview with the Medical Director on 5/20/10 at 2:00 pm, the Medical Director reviewed the physician order on 4/29/10 for Diflucan for Resident #1 and the MAR documented the first dose of Diflucan was administered to the resident on 5/4/10 at 7:30 pm, and stated, "sounds like a delay to me." When asked if he had been notified that the medication was not available, the Medical Director responded, "no."

During an interview on 5/26/10 at approximately 9:00 am with the Consultant Pharmacist, he stated that the role of the pharmacist was to review all medication error reports, however, when asked if he had reviewed the Drug/Pharmacy Incident Report for Resident #1 dated 5/4/10 signed by the DON and stated, no, if he had reviewed it, his signature would be indicated.

The facility was not able to provide documentation that a medication error report was completed.

2. Resident #9
The resident was admitted to the facility on 5/11/10 with diagnosis diabetes mellitus and Stroke. The MDS dated 5/19/10 assessed the resident to have intact cognition and memory.

Physician's orders dated 5/11/10 documented an order for Lyrica 50 mg every 8 hours (a pain medication).

The MAR dated 5/1/10 through 5/31/10 documented Lyrica 50 mg every 8 hours, 8:00 am, 4:00 pm and 12:00 am. The MAR was documented with an "x" on 5/11/10 at 8:00 am and 4:00 pm and and a blank entry at 12:00 am. Circled entries were documented for 12:00 am and for 4:00 pm on 5/12, 5/16 and 5/17/2010. On 5/18/10, the 8:00 am, 4:00 pm and 12:00 am entries were circled. The Pain Medication, Medication and Hold notes section of the MAR documented an entry on 5/17/10 at 12:01 am, "awaiting Lyrica from pharm."

Nurse's notes for 5/14/10 at 12:00 am documented that Lyrica was held due to lethargy. There was no documented evidence of notification to the physician.

Nurse's notes for 5/15/10 at 4:07 am documented at 12:00 am meds held, supervisor aware. There was no documented evidence of notification to the physician.

During an interview with RNM #1 on 5/21/10 at 11:45 am, she stated that circled, blank or entries marked with an "x" indicated that the medication ordered was not given to the resident and that a corresponding note should be made in the Pain Medication, Medication and Hold Notes section of the MAR. The RNM #1 stated that she depends on the medication nurses to advise her of unavailable medications and does not recall being made aware of missing medications for Resident #9. The RNM #1 stated that if she was aware of missing medications, she would have contacted the pharmacy to follow-up.

During an interview with LPN #4 on 5/24/10 at 10:50 am, LPN #4 stated that she was primarily scheduled on the 3:00 pm -11:00 pm shift and had a problem with medications not available to dispense to residents as ordered by the physician. LPN #4 stated that circled, blank and "x" entries indicated that the medication was not administered to the resident. LPN #4 stated that circled, blank or "x" entries should be documented on the back of the MAR in the Pain Medication, Medication and Hold Notes section to indicate the reason the medication was not administered, however, LPN #4 stated that she often does not have time to make the entry and has never called the resident's physician if a medication was not given. LPN #4 stated that she verbally notifies the supervisor. LPN #4 stated that the circled entries on Resident #9's MAR indicated that the medication was not available for administration. LPN #4 stated that when medications are running low, she peels the medication label and attaches it to a reorder sheet and faxes it to the pharmacy. LPN #4 stated that there was no system in place to communicate to others that she has faxed the order, nor does she know what orders have been placed when a delivery was received.

The facility was not able to provide documentation that a medication error report was completed
.
3. Resident #5:
The resident was readmitted to the facility on 5/13/10 after a hospital stay with diagnosis of mental status changes, dehydration and chronic obstructive pulmonary disease with oxygen . The MDS dated 4/6/10 assessed the resident with impaired short and long term memory and moderately impaired decision making ability.

The physician's order dated 5/13/10 documented an order for Augmentin 250 mg every 6 hours through 5/17/10. The physician's order dated 5/14/10 documented to change the Augmentin to 500mg by mouth twice a day through 5/19/10.

The MAR dated 5/1/10 through 5/31/10 documented Augmentin 250 mg by mouth every 6 hours through 5/1710. The MAR documented circled entries on 5/13/10 at 6:00pm 5/14/10 at 12:00 am, the Pain Medication, Medication Exception, and Hold notes section
documented on 5/14/10 at 8:00 am that Augmentin was not available from the pharmacy. Also, on 5/19/10 the 7:00pm dose was circled and below the circled entry was written , not available. This was not documented on the reverse side of the MAR under the Pain Medication, Medication Exception, and Hold notes section.

The facility policy and procedure titled, "Medication Administration" dated 4/09, section AA. documented, "if a dose of regularly scheduled medication is withheld, refused or given at a time other than the scheduled time (for example, if the resident is not in the facility at the scheduled dose time, or a started dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initiated and circled. An explanatory note is on the reverse side of the record provided for PRN documentation. If two consecutive drops of a vital medication are withheld or refused, the physician is notified."

During an interview with Licensed Practical Nurse (LPN) #1 on 5/20/10 at 9:30 am, LPN #1 stated that she had a lot of problems with medications not being available from pharmacy when needed. LPN #1 stated that as medication was needed, the medication label was peeled off, affixed to a refill form and faxed to the pharmacy. LPN #1 stated that when she realizes that a medication is not available or is running critically low and she knows she has placed an order, she informs the Registered Nurse Manager (RNM) and will sometimes contact the pharmacy by phone. LPN #1 stated that representatives from the pharmacy have often told her they didn't receive the fax and had no record of the order and that was the reason that medications were not delivered. LPN #1 stated that when this happens, she refaxed the order. LPN #1 stated that if an order was placed before the refill due date, the order would not be filled and must be ordered on the date of renewal. Ordering on the date of renewal, did not always ensure that a medication was available when needed.

During an interview with LPN #5 on 5/21/10 at 4:30 pm, LPN #5 stated that circled entries indicated that the medication was not administered to the resident according to the physician's orders. LPN #5 stated that she did not always have the time to make an entry on the back of the MAR to indicate why medications are not administered. LPN #5 stated that having medications available from pharmacy has been a problem for awhile and that supervisors and administration are aware of the problem. LPN #5 stated that when a medication was not available, she faxed the pharmacy the needed medication and wrote, "need now." LPN #5 stated that if a medication did not arrive prior to the end of the shift, other than verbally, there was not a system to communicate to other shifts that the medication has been ordered and was awaited from pharmacy. LPN #5 stated that when contact with the pharmacy was made, the pharmacy reported not receiving the fax and there was no way for nursing staff to confirm that the fax was sent.

During an interview with the RNM #4 on 5/24/10 at 1:00 pm, RNM #4 stated that medications are not always being received by the facility. This has been occurring for several months. The RNM # 4 stated he does not know what has caused the delay in the medication delivery. He stated that the RNMs are not always made aware by the nurses if there is a problem with the medication delivery.

During an interview on 5/21/10 at 4:45 pm, the Medical Director stated that medications not coming in on time to the facility was a significant problem. The Medical Director stated that when nursing staff determine that a medication was not available, they should access the Emergency Kit (E-Kit), and if the medication cannot be located in the E-kit, then the resident's physician or he should be notified.

During an interview with the pharmacy service manager (PSM) on 5/25/10 at approximately 2:00 pm, she stated the facility can phone or fax orders for medication 24 hours per day. The pharmacy makes two scheduled deliveries of medications to the facility at 1:00 pm and 9:00 pm daily. The PSM stated that routine or refill orders are filled and delivered within 48 hours and stat orders are delivered to the facility within two to three hours of receiving the order at the pharmacy. An on-call service is used after business hours (M-F 9:00 am - 9:00 pm and Saturday and Sunday 10:00 am-4:00 pm) for stat orders and were filled by a local pharmacy and delivered by the pharmacy couriers within two to three hours of the request.

During an interview with the consultant pharmacist on 5/26/10 at approximately 9:00 am, the consultant pharmacist stated that he had been aware of problems regarding medications not being available when needed and had been working with the facility to address concerns. The consultant pharmacist stated that he documented a problem with communication between the facility and the pharmacy sometime in August of 2009 and suggested a communication log book to facilitate medication ordering and delivery concerns. The consultant pharmacist stated that he was a participant in the facility Quality Assurance Committee and recalled the issue of medication availability being discussed in January of 2010.

During a telephone interview with the DON on 5/24/10 at 11:15 am, the DON stated to order medications from the pharmacy, nursing staff should write new admission orders, fax the orders to the pharmacy, call the pharmacy to advise that the orders were faxed and wait for the medications to arrive, usually around 9:00 pm. The DON stated that if medications were needed, but are not available, the nursing staff should check the Emergency Kit (E-kit), advise the pharmacy that they need the medication stat (immediately) and if the pharmacy cannot deliver the medication to be administered timely, the nursing staff should contact the resident's physician for a change in the order. The DON stated that she expected new orders to be delivered on the next scheduled delivery, daily at 1:00 pm and 9:00 pm. The DON stated that she expected that stat orders would be delivered to the facility within two to three hours and refill orders within forty-eight hours. The DON stated that the MARs that contained circled, blank or entries marked with an "x", indicated that the medication ordered was not given to the resident and that a corresponding note should be made in the Pain Medication, Medication and Hold Notes section AA of the MAR to document the reason the medication was not given.

During an interview with the DON on 5/25/10 at 9:15 am, the DON stated that approximately one month ago, she began audits and determined that the facility was not receiving medications from pharmacy when needed and the Emergency Kit did not contain the medication that it should have because as medications were being taken, forms were not being forwarded to pharmacy to replenish the E-kit. The DON stated that she believed the problem of medications not being available had surfaced within the last couple of weeks.

During an interview with the DON on 5/26/10 at approximately 8:45 am, the DON produced an audit of medications not available for 19 residents throughout the facility for the period of April 1, 2010 to May 10, 2010. The DON also produced five Drug Pharmacy Incident Reports for the period of May 5, 2010 to May 19, 2010 for which medications were not available, including the Diflucan for Resident #1. When the DON was asked why the signature lines for each the Medical Director and the Pharmacist were blank, the DON stated that she did not forward Drug Pharmacy Incident Reports to the MD or Pharmacist. The DON when asked what actions she had taken upon completion of the audit for the period of April 1 to May 10, 2010 stated she had been out of work sporadically until 5/25/10 and medication were not one of her highest priorities.

During an interview with the Administrator on 5/26/10 at approximately 10:45 am, the Administrator stated that she was aware that the DON was working with the pharmacy regarding medications that were occasionally unavailable. When asked what actions were taken upon completion of the DON's audit from April 1 to May 10, the Administrator stated that she had not seen the results of the audit. Upon review of the audit identifying medications that were unavailable to the 19 residents, the Administrator stated she was unaware of extent of the problem.

The facility was not able to provide documentation that a medication error report was completed.

10NYCRR 415.12

F490 483.75: FACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING

Scope: Widespread

Severity: Immediate Jeopardy

Corrected Date: June 30, 2010

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: May 26, 2010


Based on medical record reviews and staff interviews during a complaint investigation (Case #NY00085770), it was determined that the Administrator failed to ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the administrator failed to have systems in place to ensure that physician ordered medications were received timely from pharmacy, failed to identify and prevent potentially avoidable medication errors, and failed to ensure that all medication errors were investigated and action taken to prevent recurrence for 31 (Residents #s- 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18,19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31) of 78 residents reviewed with the potential to affect all residents. This resulted in Immediate Jeopardy to resident's health and safety and Substandard Quality of Care for residents. The evidence was as follows;

See F 309

The Administrator was interview on 5/25/10 at approximately 10:45 am and stated she was aware that occasionally medications were unavailable, however she was not aware of the extent of the unavailability of medications, the many different procedures were being utilized to obtain medications and stated the system was broken.

In an interview with the Administrator on 5/26/10 at 9:48 am she stated that she knew there was an issue with some medications not being available from the pharmacy, but was not aware that there was a pattern of this being a problem. She stated that she was aware of this issue as early as 11/09, and met with the pharmacy who re-inserviced staff about the correct way to order medications for the residents. She stated that she was often told by staff that they hated the pharmacy because they always got the run around when trying to get medications for new orders and even more so, if a medication was missing. The Administrator stated that after the pharmacy had re-inserviced the staff, she did not follow up to see if the system was running properly or if staff were ordering medications properly. She also stated that there was no policy and procedure instructing staff on what to do in the event that a medication was not available for a resident and that there should have been one. The Administrator stated that no one had ever told her that there was a wide scale problem with medication unavailability and that she was only aware of the occasional problems in this area, and stated that she could remember approximately four occasions of residents missing medication doses, because of unavailability in the last six months.

In an interview with the Administrator on 5/26/10 at 2:03 pm she stated that, in hind sight, she should have recognized that medication unavailability from the pharmacy was a problem, but statistically it didn't seem like it was as pervasive as it turned out to be.

10NYCCR 415.26

F520 483.75(o)(1): FACILITY MAINTAINS QA COMMITTEE

Scope: Widespread

Severity: Immediate Jeopardy

Corrected Date: June 30, 2010

A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Citation date: May 26, 2010

Based on medical record reviews and staff interviews during a complaint investigation (Case #NY00085770) it was determined that that the facility failed to have a Quality Assurance (QA) program that readily identified issues that have the potential to cause serious harm to residents. Specifically, the QA Committee failed to have systems in place to ensure that physician ordered medications were received timely from pharmacy, failed to identify and prevent potentially avoidable medication errors, and failed to ensure that all medication errors were investigated and action taken to prevent recurrence for 31 (Residents #s- 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18,19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31) ) of 78 residents reviewed. This resulted in one area (F309) that was identified to be Immediate Jeopardy and Substandard Quality of Care to the health and safety of residents. The evidence was as follows:

See F 309

During an interview with the Administrator on 5/26/10 at 2:03 pm, she stated that the Quality Assurance (QA) committee started meeting with the pharmacy representatives in 11/09 to address the problem of the unavailability of medications. She stated that after these meeting, she did not know if audits were being done to evaluate the effectiveness of any changes and that she was aware that the unavailability of medications was an issue. She stated that the pharmacist attended the QA meetings and that this issue was discussed in those meeting although it was not documented in meeting minutes. The discussion in QA on 4/1/10 centered around ways to fix the problem, but there was no follow-up. The Administrator also stated that the Drug/Pharmacy Incident Reports should have been reviewed more closely and that if they had been, this issue may have been identified and corrected in a more timely manner. She also stated that the QA committee should have recognized and addressed this problem.

10 NYCRR 415.27(a-c)

F501 483.75(i): RESPONSIBILITIES OF MEDICAL DIRECTOR

Scope: Widespread

Severity: Immediate Jeopardy

Corrected Date: June 30, 2010

The facility must designate a physician to serve as medical director. The medical director is responsible for implementation of resident care policies; and the coordination of medical care in the facility.

Citation date: May 26, 2010


Based on facility record review and staff interview, the facility did not ensure that the Medical Director provided clinical guidance and oversight regarding the unavailability of physician prescribed medications for 31 ( Residents #s- 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18,19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31) of 78 residents reviewed, on 2 of 2 units reviewed, during complaint investigation (#NY00085770). Specifically, the facility did not ensure that the Medical Director provided clinical guidance and oversight to ensure that the facility administered medications as ordered by the physician, identified and prevented potentially avoidable medication errors and investigated and took action to prevent avoidable medication errors. This resulted in Immediate Jeopardy to resident's health and safety and Substandard Quality of Care for r esidents. This was evidenced by the following:

See F 309

Findings
In an interview with the Medical Director (MD) on 5/26/10 at approximately 3:45 pm, the MD stated that he was unaware of the extent of the medication errors due to the unavailability of medication from the pharmacy. The MD stated that occasionally, while in the facility, he would hear about a problem with unavailability of medications and would ask the nursing staff to follow-up with the pharmacy. The MD stated he was not contacted on a routine basis if medications were not administered by nursing staff per physician orders. The MD stated that he did not recall reviewing or signing Incident and Accident Reports or Drug/Pharmacy Incident Reports related to medication errors. The MD stated as a member of the Quality Assurance Committee he did recall being involved in discussions with the pharmacy staff and administration but, did not recall when he became aware of a problem. The MD stated, "I am glad you are looking into the issue."

In a follow-up interview on 5/27/10 at 9:52 am, the MD stated that upon review of his records, he was aware that the facility was having an issue with medications not being given on time due to late deliveries from pharmacy. The MD stated that he was present for a meeting in January 2010 with the facility administration and pharmacy representatives. The MD stated there was a follow-up meeting in March 2010 however, there was no mention of the magnitude of the problem.

10NYCRR415.15(a)