Village Point

Penalty

Inspection fine: $182,266

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 deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically involving a nurse trainee (LPN #1) who administered wrong medications to two residents while on orientation with preceptors. On one occasion, LPN #1 entered a shared room occupied by Resident #2 and another resident and asked Resident #2 to state their name. Resident #2 responded with the roommate’s name, and LPN #1 did not verify the resident’s identity by checking the identification band or otherwise confirming identity as required by facility policy. As a result, Resident #2 received medications that were prescribed for the roommate, including Farxiga 10 mg, Protonix 40 mg, and Depakote 125 mg. Resident #2 later confirmed that the nurse did not check their identification band or name before administering the medications. A second significant medication error occurred when LPN #1, still in orientation, was assigned with a preceptor (LPN #2) during a day shift. The preceptor instructed LPN #1 to independently administer medications to Resident #1, who shared a room with Resident #3. LPN #1 went into the room and administered medications intended for Resident #1 to Resident #3 instead. The medications given in error to Resident #3 included Jardiance 10 mg, Metoprolol succinate 100 mg, Protonix 40 mg, PreserVision (Areds) 4296 mcg/90 mg/226 mg, and Eliquis 2.5 mg, all of which were ordered for Resident #1. A CNA present in the room questioned whether LPN #1 was going to administer medications to Resident #1 and then informed LPN #1 that the person who had just received the medications was actually Resident #3, not Resident #1. LPN #1 acknowledged that she did not follow the facility’s medication policy. Resident #3’s medical record showed active orders for a different medication regimen, including Keppra, Metformin, Amiodarone, Lipitor, Methimazole, a multivitamin, Sitagliptin, Vitamin D, and Metoprolol 25 mg, and the resident had diagnoses including muscle weakness, diabetes mellitus, acute respiratory failure, and epilepticus, with intact cognition (BIMS 13/15). After receiving the wrong medications, Resident #3 developed low blood pressure (80/50) and symptoms of hypoxia and required transfer to the emergency room and hospital admission. Resident #1, for whom the medications were actually prescribed, had a separate set of diagnoses including unspecified dementia, chronic kidney disease, overactive bladder, major depression, and a cardiac pacemaker, and was moderately cognitively impaired (BIMS 10/15). The facility’s medication administration policy required that medications be administered as prescribed and that the individual administering medications verify the right resident, right medication, right dose, right time, and right method, and explicitly prohibited administering a medication ordered for one resident to another. The survey also revealed that the orientation checklist for LPN #1 was blank and that preceptors acknowledged they did not remain with the orientee during medication passes, despite the orientee being in training and identified as not safe to pass medications independently.