Regal Heights Rehabilitation and Health Care Center

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that professional standards of quality were met. This was evident in 2 of 3 sampled residents (Residents #1 and #3). Specifically, Resident #1 had a Physician order for Calcium 500 milligrams (mg) plus Vitamin D 200 International Units (IU). The order was not transcribed onto the Medication Administration Record (MAR) and the order was not reconciled by the following two shifts. As a result, the medication was not administered to Resident #1. Additionally, the nursing staff did not properly transcribe an order for Intravenous Fluids (IVF) onto the MAR. The MAR did not include entries for all 3 oncoming shifts. Resident #3 had an order for Potassium Chloride, which was not reconciled by the two following shifts.

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

This was evidenced by 2 out of 3 sampled residents (Resident #1 and #3).

Complaint # NY00087032

The findings are:

Resident # 1 is a 63 year old female admitted to the facility on 5/21/2010. The resident's diagnoses included Hypertension, Osteoarthritis, Status Right Post Total Hip Replacement, Status Post Rapture Perforated Colon and Status Post Stent Cardiac.

The Minimum Data Set 2.0 (a resident assessment tool), dated 5/25/10 identified that the resident had intact short and long term memory with independent cognitive skills for daily decision making. Resident #1 required extensive assistance of 1 staff and supervision /set up help in eating.

A nurse's note dated 5/28/10 at 3:20PM revealed that the resident complained of pain. The Physician was made aware and ordered Calcium 500mg + Vitamin D 200 IU one tablet every day with lunch.

A review of the Interim Physician order dated 5/28/10 at 3:26PM documented Calcium 500mg + Vitamin D 200 International Units tablet one tablet by mouth, one time a day with lunch for supplement. The Physician order was signed by the 7:00AM-3:00PM nurse on 5/28/10. The Physician order form did not document that the order was reviewed and signed by the 2 oncoming consecutive shifts. The order was signed as reviewed on 6/6/10 11PM-7:00AM shift and on 6/11/10 during the 7:00AM-3:00PM shift.

A review of the MAR initiated on 5/21/10 revealed that Calcium 500mg + Vitamin D 200 IU was not transcribed onto the MAR as per the Physician order.

The Physician Interim order dated 6/3/10 at 3:43PM documented Intravenous Fluid (IVF) Dextrose 5 Normal Saline at 60 ml/hour for 24 hours for Hydration/ Refuse to Eat. A review of the MAR dated 6/3/10 revealed that IVF was started at 4:30PM and signed by the nurse. The MAR order transcription did not include entries for the oncoming shifts (11:00-7:00AM and 7:00AM- 3:00PM) in order to verify administration of IV Fluids for 24 hours.

On 6/4/10 the Physician Interim order continued the current IVF for another 24 hours. A review of the MAR for 6/4/10 revealed Dextrose 5 Normal Saline rate 60ml to continue for another 24 hours. The MAR transcription did not include when the IVF was started. The MAR also did not include entries for all 3 shifts in order to verify administration of IV Fluid.

On 6/15/11 at 11:00AM the Licensed Practical Nurse (LPN) # 1 was interviewed. She stated that on 5/28/10 she worked from 7:00AM-3:00PM and 3:00-9:00PM. The LPN stated that on 5/28/10 she did not pick up the order for Calcium 500 mg + Vitamin D 200 IU for Resident #1. The LPN admitted that she was responsible for picking up the order on that day. She stated that the resident did not get the medication for leg cramps as per Physician order due to her omission.

Resident # 3 is a 92 year old female admitted to the facility on 8/24/2009; her diagnoses include Gastroesophageal Reflux Disorder (GERD), Coronary Artery Disease, Hypertension and Dementia. The Minimum Data Set 3.0 dated 4/7/10 identified that the resident had severe impairment in cognition. She required supervision in eating and extensive assistance of 1 staff in personal hygiene.

An Interim Physician order, dated 4/27/10 included an order for Potassium Chloride 10% (40MEQ/15ML), give 40 MEQ liquid by mouth daily. The order was picked up on 4/27/10 during the 3:00PM-11:00PM shift. The order was not reviewed by the two oncoming shifts. It was reviewed on 4/29/10 during the 7:00AM-3:00PM and on 5/4/10 by the 7:00AM-3:00PM.

The Policies and Procedures on Physician Order Transcription revised on 6/2008 documented that the Registered Nurse initiates a Physician order via telephone. The telephone order is read back and confirmed with the Physician. A licensed nurse transcribes the complete order, including name of medication, strength, route of administration and frequency onto the MAR (out of cycle medication orders.) The licensed nurse ensures that the nurses from the next two, consecutive shifts countersign the printed physician order.

On 5/9/11 at 1:10PM the Director of Nursing (DON) was interviewed. She stated that any licensed nurse can put an order in the computer but only the Registered Nurse (RN) submits the order electronically to the pharmacy. Once the interim orders are picked up by the licensed nurse, they are transcribed in the MAR/Treatment Administration Record (TAR) to be checked and counter-signed by any licensed nurse on the next 2 shifts and initialed at the bottom of the Physician order form on the appropriate box. The DON stated that the Physician order is checked against the MAR/TAR for accuracy within 24 hours. Regarding IVF administration, the DON stated that the order is supposed to be transcribed to the MAR with an entry for each shift. The DON acknowledged that the facility policy and procedures regarding order transcription were not followed.

On 7/18/11 at 3:10PM a telephone interview was conducted with RN # 5. She stated that interim orders are picked up by a licensed nurse and must be reviewed and signed by the following 2 shifts within 24 hours per policies and procedures.

On 7/19/11 at 2:45PM a telephone interview was conducted with RN # 4 . She stated that the interim order for IVF for Resident #3 on 4/27/11 was not picked up and reviewed by the 3 shifts within the time frame per policies and procedures.

415.11 (c) (3) (i)