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F0684
E

Identification Band Deficiency on Dementia Unit

Brewster, New York Survey Completed on 12-16-2024

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by the absence of identification bands on 12 out of 39 residents observed on the Apple unit. The facility's Medication Administration policy requires nurses to verify a resident's identification by checking their identification band before administering medication. However, during an observation, it was noted that these residents did not have identification bands in place, which is a critical step in ensuring the correct administration of medications. Interviews with staff revealed that Licensed Practical Nurse #1 had to rely on other staff members or the electronic medical record system to identify residents during medication administration due to the lack of identification bands. Registered Nurse #1 acknowledged the issue and stated that they conduct audits to replace missing bands, but residents on the Apple unit, which is a dementia unit, frequently remove their bands. The Director of Nursing confirmed the ongoing issue and emphasized the need for regular checks to ensure identification bands are in place, particularly on the dementia unit where residents are prone to removing them.

Plan Of Correction

Plan of Correction: Approved December 30, 2024 Plan for Affected Resident: All 12 Residents affected were given new wrist bands. Plan to identify other potentially affected residents: All residents’ wrist bands were checked on each unit. All residents had wristbands in place. Plan for system changes and measures to prevent occurrence: The facility medication administration policy was reviewed. The policy was updated. All nursing staff were educated with emphasis on verification of residents by checking the residents’ name and medical record number on their wrist bands. If a resident does not have a wristband, they can verify via EMAR picture and continue their medication administration. The LPN is to create a wristband for any resident without a wristband by the end of the shift. All LPNs including nurse 1, were re-educated on the facility medication administration policy with emphasis on resident identification bands. Plan for monitoring correction action: Weekly audits will occur for one month on 15 residents per unit by the ADON/Unit Managers/Designee to ensure that all residents are wearing an identification band. After one month the wristbands will be audited biweekly for an additional two months. After two additional months wristband audits will be conducted monthly. All results will be reported at the quarterly quality measure meeting.

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