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Home  /  Medication Errors  /  Warren Center for Rehabilitation and Nursing: Pressure Ulcer Citation

Warren Center for Rehabilitation and Nursing: Pressure Ulcer Citation

by Law Offices of Thomas L. Gallivan, PLLC 11 Jan2022

Warren Center for Rehabilitation and Nursing has received 73 citations for violations of public health code between 2017 and 2021, according to New York State Department of Health records accessed on January 7, 2022. The facility has additionally received three fines totaling $14,000 since 2011, the most recent being a $10,000 fine issued in December 2017. The Queensbury nursing home’s citations resulted from a total of eight surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not adequately prevent the use of unnecessary medications. Section 483.45 of the Federal Code stipulates that nursing home residents’ drug regimens “must be free from unnecessary drugs.” A September 2021 citation found that Warren Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that one resident received an opioid pain medication even though their medical record did not include a clinical indication supporting its use, nor documentation to support an increase in dosage. In an interview, one of the facility’s Certified Nursing Assistants said that “they did not provide non-pharmacological interventions for pain management for this resident and the resident was not care planned for specific interventions for the nurse assistants to provide.” A plan of correction undertaken by the  facility included the re-education of licensed nurses on policy regarding medication administration.

2. The nursing home did not provide adequate pressure ulcer care. Section 483.25 of the Federal Code stipulates that nursing homes must ensure residents with pressure ulcers receive necessary treatment and services in accordance with professional standards and practices. A September 2021 citation found that Warren Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that the facility failed to ensure one resident received pressure ulcer wound care in accordance with their physician’s orders or with professional standards. The citation goes on to describe a nurse’s failure to adequately apply cream to the wound area as ordered by the facility’s physician. In an interview, the nurse said that “they did not realize” the physician’s orders included the application of cream to the base of each wound bed as well as the peri-wound area. A plan of correction undertaken by the facility included the re-education of licensed nurses.

3. The nursing home did not maintain sufficient nursing staff. Section 483.45 of the Federal Code stipulates that nursing home facilities “must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable… well-being of each resident.” A September 2021 citation found that Warren Center for Rehabilitation and Nursing failed to ensure such. The citation states specifically that the facility’s staffing plan was not met on 3 out of 3 consecutive weekends, and further that the facility failed to ensure each resident in one unit received Activities of Daily Living… care before 10:30 AM. A plan of correction undertaken by the facility included the completion of a daily audit to ensure adequate staffing.

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

Posted in: Medication Errors, Nursing Home Violations, Pressure Sores, Understaffing

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