Chautauqua Nursing And Rehabilitation Center

Penalty

No penalty information released

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 proper consultation with a resident's physician when there was a significant need to alter treatment, specifically regarding the administration of the medication Nuplazid. The resident, who was cognitively intact and had a history of falls and behavioral issues, was prescribed Nuplazid to manage behaviors such as crawling on the floor and aggression towards staff. However, due to insurance constraints, the medication required reordering every 14 days, which the facility failed to manage effectively, resulting in 20 missed doses over two separate periods. The facility's policy required immediate notification of the nursing supervisor and the medical provider when medications were not available, but this protocol was not followed. The nursing staff did not inform the resident's physician about the missed doses or the need to reorder the medication, leading to a lapse in treatment. Interviews with staff revealed that there was a lack of a systematic approach to ensure timely reordering of the medication, and during a transition period between unit managers, the responsibility for reordering was not adequately managed. The resident's neurologist/psychiatrist and the facility's medical director both expressed that they should have been informed of the medication lapse. The consultant pharmacist noted that stopping Nuplazid abruptly could lead to the reemergence of behaviors and hallucinations. The facility's failure to adhere to its protocols for medication management and physician notification resulted in a significant deficiency in the resident's care.

Plan Of Correction

Plan of Correction: Approved March 27, 2025 1. Resident #1 was assessed for 5 consecutive days and reviewed with the Medical Director and determined to have no current negative outcomes. Care plan was reviewed and in concert with the resident’s needs. Medication error report was completed and shared with the IDT member, physician, pharm consultant and dispensing pharmacy. Consultant ordering Psychiatrist was updated on the omission and a follow up visit was provided/pending. 2. All residents experiencing changes in conditions or falls have the potential to be affected by this deficient practice. The DON conducted a review of all residents currently in the facility experiencing changes in condition, medications not being administered as ordered and falls to determine physician notifications were completed. No other deficiencies were found. 3. Measures that were put in place to ensure the deficient practice does not recur. The Unit Manager was educated on the policies titled Medication/Treatment Administration Documentation and Change in Resident's Condition, Medication/Treatment or status. The DON will conduct an audit of 10 residents a week with falls and/or a change in medical conditions to determine notification to the physician until 100% compliance for 4 consecutive weeks is sustained. Included in the audit will be a review to determine that the medical provider was notified of missed medication doses. The policies were reviewed and no changes were necessary. All staff responsible for Medication Administration Documentation were educated on the policy titled Medication/Treatment Administration Documentation. All staff responsible for Physician notifications and family notifications regarding changes of care and resident condition were educated on the policy titled Change in Resident's Condition, Medication/Treatment or status. The facility reviewed all orders with 14 day renewals on the MAR / TAR and changed the orders to standing orders so the order will not fall off. The Pharmacy will send reminders if additional authorization is needed prior to filling the medication. 4. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be immediately counseled. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 5. Corrective action will be completed by 05/18/2025. The Director of Nursing Services is responsible for implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.

Penalty

No penalty information released

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 pharmaceutical services met the needs of a resident, specifically in the acquisition and administration of the antipsychotic medication Nuplazid. The resident, who was cognitively intact and had a history of falls, paranoid thoughts, and hallucinations, was prescribed Nuplazid to manage these symptoms. However, the medication was not administered for 20 doses due to lapses in reordering, which was required every 14 days per insurance policy. The facility's policy required that medication discrepancies be reported and addressed, but no medication error reports were completed for the missed doses. The deficiency occurred because the Licensed Practical Nurse (LPN) Unit Manager was unaware of the need to physically write a new order every 14 days for the medication, mistakenly believing it could be reordered like other medications. This misunderstanding led to periods where the medication was not administered, contributing to the resident's behavioral issues, such as refusing care and placing themselves on the floor. The facility's interim Director of Nursing acknowledged that the medication required a new prescription every 14 days and that the cart nurses were responsible for alerting unit managers when the medication was running low. Interviews with the Neurologist/Psychiatrist and the Consultant Pharmacist highlighted the importance of Nuplazid for the resident's mental health and the risks associated with abruptly stopping the medication. The facility's failure to reorder and administer the medication as prescribed resulted in the resident not receiving the necessary treatment to manage their condition. The Medical Director emphasized the facility's responsibility to ensure residents receive their medications as ordered and to notify the physician if there are any lapses in administration.

Plan Of Correction

Plan of Correction: Approved March 27, 2025 1. Resident #1 had an immediate review of his Medication Administration Record [REDACTED]. Resident was assessed and monitored for 5 consecutive days to monitor for adverse effects. None were noted. MD was notified regarding medication omission. Medication error report was completed and shared with the IDT member, pharm consultant and dispensing pharmacy. Resident’s care plan was reviewed and in concert with residents current needs. A reminder was added to the DON, ADON and Unit Managers calendars every 14 days for Res #1's Nuplazid renewal. An additional order was entered to reorder the medication every 14 days to trigger the medication nurse to ensure medication is reordered timely. 2. All residents on 14 day renewal medications, with medications that have special medication ordering needs or medications requiring a new script have the potential to be affected by this deficient practice. The facility reviewed all other residents to ensure there were no other special medication ordering needs. None were identified. The DON conducted a full house audit of all residents on medications requiring a new script or preauthorization and no other issues were found. The facility changed all orders with 14 day renewals on the MAR / TAR to be entered as standing orders so that a new script is not required each time so this problem does not recur. The pharmacy will notify the facility if a preauthorization is needed. 3. The Unit Manager was educated on the Ordering Medications/Treatments from Pharmacy policy and the Medication/Treatment Discrepancy/Error policy. The policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error were reviewed and no changes were necessary. 4. Measures that were put in place to assure the deficient practice does not recur: - All staff responsible for Medication / Treatment Administration were educated on the policies titled Ordering Medications/Treatments from Pharmacy and Medication/Treatment Discrepancy/Error. - The DON will conduct weekly audits of the resident population with 14 day renewals to ensure orders are present. All current and new 14 day renewal orders will be audited weekly until 100% compliance is sustained x 4 weeks. If 100% compliance is not found, the staff involved will be counseled immediately. 5. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Quality Improvement Committee may make further recommendations including, but not limited to ongoing education, additional audits and/or process changes. 6. The Director of Nursing will be responsible for monitoring compliance of the corrective plan with the facility administrator having overall responsibility for the conduct of the plan. Corrective action will be completed by 05/18/2025.

Penalty

No penalty information released

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 adequate supervision and use of assistive devices to prevent accidents for a resident, leading to a fall. The resident, who had diagnoses including hemiplegia, hemiparesis, malignant neoplasm of the brain, and vascular dementia, was cognitively intact and understood instructions. The comprehensive care plan indicated that the resident was at risk for falls due to cognition, mobility, and right-sided weakness, requiring supervision while on the toilet and a sit-to-stand lift with two-person assistance for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) assisted the resident onto the toilet using the sit-to-stand lift but left the resident alone in the bathroom, contrary to the care plan's requirement for supervision. The CNA was unaware of the care plan intervention requiring supervision and admitted to not checking care plans often. As a result, the resident attempted to reach for a urinal, unhooked the lift belt, and fell, sustaining a bruise to the head and experiencing hip and knee pain. Interviews with staff revealed that the expectation was for CNAs to check the Kardex daily, but the CNA involved did not adhere to this practice. The Director of Nursing and other staff emphasized the importance of following care plans to prevent accidents and injuries. The incident highlighted a break in the care plan, which was not followed, leading to the resident's fall and subsequent injuries.