Citations in New Hampshire
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Hampshire.
Statistics for New Hampshire (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in New Hampshire
- The facility conducted a Quality Assurance (QA) meeting, evaluated the affected residents with provider-ordered hepatitis and HIV testing, performed a facility-wide audit of insulin availability, provided education and competencies on medication protocols, insulin pen policies, and CDC injection safety, and initiated an insulin inventory sheet. (J - F0880 - NH)
- Staff received in-service training on proper insulin pen administration and the prohibition of using another resident's insulin. Audits were conducted to ensure no additional missing insulin, and staff competencies were reinforced prior to first shifts. A root cause analysis was performed, and the incident was reported to New Hampshire Public Health for follow-up. (J - F0880 - NH)
- The facility updated its insulin administration policy, provided in-service education to all nurses specifically on administering Humulin R U-500 insulin pens, conducted competency evaluations, initiated weekly audits of insulin administration, and planned to review these audits during quarterly Quality Assurance and Performance Improvement meetings. (J - F0760 - NH)
Improper Use of Insulin Pen for Multiple Residents
Penalty
Summary
The facility failed to ensure residents were free from exposure to bloodborne pathogen transmission when staff used one insulin pen to administer insulin to two residents on multiple days. Specifically, a Licensed Practical Nurse (LPN) used a Lantus insulin pen designated for one resident to administer insulin to another resident on two consecutive days. This pen was then returned to the medication cart and subsequently used again for the original resident without the knowledge of another LPN, who was unaware of the pen's prior use for a different resident. The facility's records confirmed that both residents had active physician's orders for Lantus insulin, which was administered according to the schedule. However, the use of a single insulin pen for multiple residents contravened the manufacturer's instructions, the facility's pharmacy policy, and the Centers for Disease Control and Prevention (CDC) guidelines, all of which emphasize that insulin pens are for single-patient use only to prevent the risk of bloodborne pathogen transmission.
Removal Plan
- QA meeting was conducted
- The provider evaluated Resident #1 and Resident #2 and ordered Hepatitis panel and HIV blood tests and a retest for the hepatitis panel and HIV blood test was ordered
- Facility-wide audit of all residents insulin availability was conducted
- Education and competencies of facility's medication availability protocol, facility's insulin pen policy, and CDC's injection safety were conducted
- Insulin inventory sheet was created and initiated
Insulin Pen Misuse Leads to Pathogen Exposure
Penalty
Summary
The facility failed to ensure that a resident was free from exposure to bloodborne and bacterial pathogen transmission when a registered nurse administered insulin from another resident's used insulin pen. The incident occurred when the nurse was unable to locate the resident's prescribed Humalog 75/25 insulin or any backup stock in the medication room for the scheduled dose. Consequently, the nurse used another resident's Humalog 75/25 insulin pen, which had already been opened and used, to draw up 10 units of insulin with a syringe and administer it to the resident. The facility's policy explicitly prohibits borrowing medication from another resident and sharing insulin pens due to the risk of infection transmission. The Humalog Mix 75/25 KwikPen insert and the CDC guidelines both emphasize that insulin pens should not be shared between individuals, as backflow of blood can occur, posing a risk of pathogen transmission. The facility's pharmacy policy also states that prefilled pen devices should never be accessed with a syringe and needle, and the same pen should not be used for more than one resident.
Removal Plan
- In-service staff regarding administration of insulin pens and not using another resident's insulin.
- Conduct audits for all residents to ensure no additional missing insulin.
- Start in-service training for insulin pen administration, medications not available, and abuse/misappropriation.
- Train all staff on competencies for medication not being available, abuse, insulin pens, following physician's orders, and insulin replacement prior to working their first shift.
- Conduct a root cause analysis and review audits as part of the Ad Hoc Quality Assurance and Performance Improvement meeting.
- Notify New Hampshire Public Health regarding the incident and follow up.
Insulin Overdose Due to Syringe Misuse
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in a resident receiving an overdose of insulin. The error occurred when a registered nurse used a U-100 insulin syringe instead of a U-500 syringe to administer Humulin R U-500 insulin from the resident's insulin pen. This mistake led to the resident receiving five times the prescribed dose of insulin on two separate occasions. The manufacturer's instructions for Humulin R U-500 clearly state that the insulin should not be transferred from the pen into a syringe, as this can lead to severe overdoses and dangerously low blood sugar levels. As a result of the overdose, the resident experienced hypoglycemia, with blood glucose levels dropping to as low as 40 mg/dL. The resident became lethargic and was only arousable with repeated stimuli, necessitating the administration of insta glucose gel and subsequent transfer to the hospital for evaluation and treatment. The resident's medical records indicated several episodes of hypoglycemia overnight, confirming the severity of the medication error.
Removal Plan
- Updated the policy titled: Insulin
- Completed in-service education to all nurses on the administration of insulin with an insulin pen specific to Humulin R U-500
- Conducted competencies with all nurses on the administration of insulin with an insulin pen
- Monitoring insulin administration through weekly audits
- Reviewing these audits at quarterly Quality Assurance and Performance Improvement meetings
Latest Citations in New Hampshire
A resident was found self-administering Refresh tears and Fluticasone nasal spray without a clinical assessment or provider order, contrary to facility policy requiring evaluation and authorization for self-administration. Staff confirmed that the necessary assessment and orders were not completed.
A resident with a history of taking and concealing dangerous items, as well as threatening staff and other residents, did not have a care plan addressing these behaviors. Staff were aware of the resident's actions, and unsecured items like scissors were observed on the medication cart, but no interventions or goals were documented in the care plan to address the safety risks.
A medication cart was found with an unlabeled cup containing multiple pills, including a controlled substance, that had been pre-poured by a night shift LPN and left for a day shift RN to administer to a resident. The medications were not prepared and administered by the same nurse, and the controlled substance was not double locked, violating both professional standards and facility policy.
A resident with a history of wandering, taking items, and making threats was able to access and hide scissors on multiple occasions, including obtaining them from a medication cart left unattended by an RN. Staff confirmed that scissors were not always secured, resulting in an environment with accident hazards and insufficient supervision.
Pharmacist recommendations from monthly MRRs regarding medication necessity and monitoring for three residents were not reviewed or addressed by providers in a timely manner, as required by facility policy. Delays included recommendations for reviewing pain medication, ordering a lipid panel, and assessing the ongoing need for a GI medication, with some recommendations not addressed at all.
A resident was prescribed Seroquel for confusion and agitation despite no documented behavioral symptoms or significant psychiatric diagnosis. The medical record did not provide adequate justification for the ongoing use of the antipsychotic, contrary to facility policy requiring a specific indication for psychoactive medications.
A resident was given another resident's evening medications, including Lantus, Lyrica, and oxycodone, despite not having orders for all of these drugs and being prescribed a lower dose of insulin. The error occurred when staff failed to properly identify the resident before administering medications, as required by facility policy.
Surveyors found that medications, including inhalers and insulin, were not properly labeled with opening or expiration dates, and a medication cup containing a controlled substance was left unsecured in a medication cart. Nursing staff confirmed these lapses, which were not in accordance with facility policy or manufacturer instructions.
An LPN was observed storing an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) in the medication refrigerator without documenting the open date or expiration date, contrary to manufacturer instructions and facility policy requiring such labeling for product integrity.
Surveyors found that food items in the kitchen were not stored according to professional standards, with several items lacking proper labeling, dating, or covering, and some foods being kept beyond recommended timeframes. The facility's own policies and the FDA Food Code require proper storage, labeling, and timely use or disposal of food, but these procedures were not followed, as confirmed by dietary staff.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A deficiency was identified when a resident was observed to have a bottle of Refresh tears and Fluticasone nasal spray on their bedside table, which the resident reported self-administering 1-2 times daily since admission about a month prior. Despite these observations, there was no documentation in the resident's medical record of an assessment to determine if self-administration of these medications was clinically appropriate. Additionally, there were no physician orders for either medication. Further review of facility policy revealed that residents requesting to self-administer medications must undergo a self-administration evaluation by a licensed nurse to assess safety and understanding, and a healthcare provider's order is required. The policy also specifies that residents should be instructed on safe storage of medications, including the use of a locked box. Staff confirmed that these procedures were not followed for this resident.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Unsafe Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's behaviors that posed safety risks to themselves and others. Documentation showed that the resident repeatedly obtained and concealed potentially dangerous items such as scissors and a stapler, sometimes refusing to relinquish them when approached by staff. The resident also exhibited behaviors such as taking items from the medication cart, hiding them in their room, and threatening staff when attempts were made to retrieve these items. Additionally, the resident was observed attempting to access staff offices and locked cabinets, and had a documented history of being physically threatening to both residents and staff. Despite these incidents, a review of the resident's care plan revealed no documented focus, goals, or interventions addressing the resident's unsafe behaviors or the risk of physical threats. Staff interviews confirmed awareness of the resident's actions and history, yet no specific care plan strategies were in place to mitigate these risks. Observations further revealed that potentially dangerous items, such as scissors, were left unsecured on the medication cart, accessible to residents. The Director of Nursing confirmed the absence of appropriate care plan interventions for the resident's behaviors.
Failure to Follow Professional Standards for Medication Preparation and Administration
Penalty
Summary
A deficiency was identified when a medication cart was observed to contain an unlabeled medication cup with pills, including three unidentifiable pills, in the top drawer. The cup was tipped on its side, and the pills were not secured. Staff interviews confirmed that the medication cup was intended for a specific resident, and that the medications had been prepared by the night nurse but were administered by a different nurse on the day shift. The day shift nurse did not prepare the medications themselves, contrary to professional standards and facility policy, which require that nurses only administer medications they have prepared. Further review revealed that the medications included controlled substances such as Oxycodone, which was not double locked as required. The facility's policy explicitly prohibits pre-pouring medications and mandates that administration and documentation occur at the time of the medication pass. The night nurse admitted to preparing the medications in advance and leaving them in the cart for the day nurse to administer, resulting in a failure to follow both professional standards and facility policy for medication storage and administration.
Unsecured Scissors and Inadequate Supervision Lead to Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by not securing scissors when not in use, specifically for one resident with a history of wandering, taking items from others, and exhibiting physically threatening behavior. Observations showed that this resident was able to access and hide scissors in their room, and staff documented multiple incidents where the resident obtained scissors from various sources, including a medication cart and a family member. Staff also reported that the resident had threatened to stab a staff member, leading to changes in staff assignments. Additionally, during observation, scissors were found left unattended on a medication cart while a nurse was administering medication in another room. Staff confirmed that the scissors were not secured. The combination of unsecured sharp objects and a resident with a known history of wandering, taking items, and making threats contributed to the facility's failure to provide adequate supervision and prevent accident hazards.
Failure to Timely Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that providers reviewed and addressed irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) in a timely manner for three out of five residents reviewed for unnecessary medications. For one resident, the pharmacist recommended reviewing the continued necessity of Gabapentin for post-herpetic neuralgia, but the physician did not address this recommendation until nearly two months later. Another resident was receiving Lipitor, and the pharmacist suggested a lipid panel be considered with the next lab draw and at least annually, but this recommendation was also not addressed by the physician until almost two months after it was made. For a third resident, the pharmacist recommended considering tapering or discontinuing Protonix, or documenting the medical necessity and risk versus benefit of continued therapy. There was no documentation that the provider reviewed or addressed this recommendation, and the resident continued to receive Protonix for acid reflux. The facility's policy requires that pharmacist recommendations be communicated and acted upon in a timely fashion, with a response prior to the next MRR, but this was not followed in these cases. Interviews with the Director of Nursing confirmed that the recommendations were not reviewed or addressed as required.
Failure to Ensure Antipsychotic Medication Was Clinically Indicated
Penalty
Summary
A resident was prescribed Seroquel, an antipsychotic medication, at a dose of 25 mg daily for confusion and agitation. The resident's medical record indicated a diagnosis of mild vascular dementia with anxiety, but there was no significant past psychiatric history documented. Review of behavioral monitoring records showed that the resident did not exhibit any behavioral symptoms over a one-month period. Additionally, psychiatric evaluations noted the absence of significant psychiatric diagnoses and described the dementia as unspecified without behavioral disturbance and of low severity. Despite the ongoing prescription of Seroquel, there was no documented evidence of a specific condition or targeted behavior that warranted the use of this psychoactive medication, as required by the facility's policy. The family had refused a gradual dose reduction, but the clinical record lacked justification for the continued use of the antipsychotic. This failure to ensure an adequate indication for the antipsychotic medication resulted in the resident's drug regimen not being free from unnecessary drugs.
Resident Given Another Resident's Medications Due to Identification Failure
Penalty
Summary
A significant medication error occurred when a resident was administered another resident's evening medications, including 30 units of Lantus, 75 mg of Lyrica, and 5 mg of oxycodone, despite not having physician orders for Lyrica or oxycodone and only being prescribed 10 units of Lantus for diabetes. The error was documented in the nursing notes and confirmed by the Director of Nursing. The resident's medical record indicated that the medications were given along with the resident's usual nightly 4 ounces of scotch. Review of the facility's Medication Pass Policy revealed that staff are required to identify each resident prior to medication administration, but this protocol was not followed, resulting in the medication error.
Failure to Properly Label and Secure Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not labeled and stored according to professional standards on two of three medication carts. Specifically, several residents' inhalers were found opened without a date of opening, and one inhaler was labeled with an expiration date that had already passed. Additionally, an insulin pen was labeled with an expiration date, but it was unclear if it was within the manufacturer's recommended usage period after opening. These findings were confirmed through interviews with nursing staff, who acknowledged the lack of proper labeling and dating on the medications. Further observations revealed that a medication cup containing pills, including a controlled substance (Oxycodone), was left unlabeled in the top drawer of a medication cart and was not double-locked as required for controlled substances. Interviews with both the day and night shift nurses confirmed that the night nurse had pre-poured the morning medications and left them unsecured for administration by the day nurse. Review of the facility's policies and manufacturers' instructions confirmed that these practices were not in compliance with established procedures for medication labeling, dating, and secure storage.
Failure to Label Open Multi-Dose Injectable Medication
Penalty
Summary
During an observation in the Chase Unit medication room, an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) was found in the medication refrigerator without an open date or an open expiration date. This was confirmed by an LPN present at the time. Review of the manufacturer's instructions indicated that a vial in use for 30 days should be discarded, and the facility's own policy required multi-dose vials to be labeled with the date opened to ensure product integrity. The lack of labeling on the vial was not in accordance with both manufacturer instructions and facility policy.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's kitchen. Items found included a small dish of salad covered in plastic wrap without a preparation or use by date, a container of tuna fish labeled with a preparation date, a container of chicken salad with a preparation date, and a bowl of cooked potatoes that was uncovered and undated. Additionally, thawed chicken breasts, cucumbers that were leaking fluid and had black spots, and thawed sliced deli meats with dates indicating they had been pulled from the freezer well beyond recommended timeframes were found in the walk-in refrigerator. These findings were confirmed by the dietary cook during the survey. A review of the facility's food storage policies revealed requirements for all foods to be wrapped or in covered containers, labeled, dated, and arranged to prevent cross-contamination. The policies also specified storage timeframes for ready-to-eat and raw foods. The FDA Food Code was also referenced, which outlines standards for date marking, storage, and discarding of foods to prevent contamination. The facility failed to follow these professional standards and its own policies, resulting in the cited deficiency.