Bedford Hills Center

In the surveyor’s words

From the most serious findings on record at Bedford Hills Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760May 22, 2024

  Based on interview and record review, it was determined that the facility failed to ensure residents remain free from significant medication errors, which resulted in a resident needing interventions for hypoglycemia, including hospital observation for one of three residents reviewed for insulin use. (Resident Identifier #1). Findings include: Interview on 5/22/24 at approximately 10:00 a.m. with Resident #1 revealed he/she had received too much insulin a little while ago and ended up going to the hospital as a result. […]

• Immediate jeopardy, isolatedF760Mar 21, 2022

  Based on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors which resulted in actual harm that was immediate in which the resident had pain and vision changes to both eyes for 1 of 1 residents reviewed. (Resident Identifier is #1.) Findings include: Review on 3/18/22 at approximately 9:00 a.m. of Resident #1's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Scheduled to be given at 6 a.m., 2 p.m. and 8 p.m. Interview on 3/18/22 at approximately 9:40 a.m. with Resident #1 revealed that on 2/20/22 they received ear drops instead of their scheduled eye drops to both eyes. […]

• Actual harm, isolatedF600Mar 21, 2022

  Based on observation, interview, and record review, the facility failed to ensure that a resident was free from neglect when a medication was administered via the wrong route and evaluation and treatment by a specialist was delayed for eight days which resulted in actual harm in which the resident had pain and vision changes to both eyes for 1 of 1 residents reviewed for neglect. (Resident identifier is #1.) Findings include: Review on 3/18/22 at 9:00 a.m. of Resident #1's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Scheduled to be given at 6 a.m., 2 p.m. and 8 p.m. Interview on 3/18/22 at approximately 9:40 a.m. […]

• No harm, potential for more than minimal, patternF886Apr 15, 2021

  Based on interview and record review, the facility failed to test residents and staff, based on parameters set for by the Secretary, for outbreak (any new case of COVID-19) testing. Findings include: Review of the Centers for Medicare and Medicaid Services' QSO-20-38-NH Memo, dated 8/26/20, revealed the following: An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home onset COVID-19 infection in a resident . Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. […]

• No harm, potential for more than minimal, isolatedF760Oct 3, 2024

  Based on interview and record review, it was determined that the facility failed to ensure that a resident was free from significant medication errors for 1 resident out of 3 residents reviewed for anticoagulant medications (Resident Identifier #3). Findings include: Review on 10/3/24 of Resident #3's Hospital Discharge Medication Record, dated 7/11/24, revealed the following: Resident #3 has a discharge diagnosis of a saddle pulmonary embolism. Review also revealed that Resident #3 had an order for Apixaban 5 mg [milligrams] oral tablet [medication used to prevent blood clots], take 2 tablets, 10 mg, by mouth twice a day for 7 days followed by 1 tablet (5 mg) twice daily. […]