Blossom South Nursing and Rehabilitation Center, located in Rochester, NY, was recently found deficient by the Department of Health in a multitude of areas according to a September, 2012 Certification Survey. Among the areas of substandard care noted by the DOH were failure to keep residents’ drug regimens free of unnecessary drugs; failure to establish an infection control program; and failure to keep the facility free of accident hazards.
The most serious of the deficiencies involved the use of unnecessary drugs, earning the label of “actual harm” from the DOH. This is the third (out of four) highest level of deficiency that a nursing home can receive from the Department, defined as follows on the Department of Health website: “The deficiency has resulted in noncompliance of the requirements and has resulted in a negative outcome that has compromised the resident’s ability to each the highest practicable level of functioning.”
At issue for the resident at Blossom who was exposed to actual harm was a failure of the staff to monitor the effects of blood thinning medication on the resident. The resident displayed bleeding gums and unexplained bruising, however according to the report, these symptoms were not brought to the attention of the treating physician in a timely manner. When the staff did eventually notify the physician, blood tests were performed and the facility determined that the resident needed hospitalization due to a critical level of internal bleeding.
The section of the CFR, 483.25(l) noted in the report, defines an unnecessary drug as one used in excessive dose or without adequate monitoring. Staff is responsible for this monitoring, and it is the staff’s duty to inform the physician of an abnormal behavior or symptoms. In this way the physician can make an accurate assessment of the drug regimen before serious consequences arise. Although eventually the treating physician was notified in the case of this resident, the staff did not notify him immediately, as protocol would have dictated. Unfortunately this lapse cause the resident to suffer the consequences.
As mentioned above, Blossom South was cited for a litany of deficiencies in the September 14, 2012 report–far too many to list here. The full report featuring all of the areas of substandard care that the Department of Health recorded against Blossom South can be found here on the DOH website.
