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Uihlein draws major fine

Inspection after accidental overdose, death last summer found widespread deficiencies

June 17, 2009
By JESSICA COLLIER, Enterprise Staff Writer

Adirondack Medical Center's Uihlein nursing home in Lake Placid has been fined $75,497 for a number of quality-of-care issues, including a death following an accidental drug overdose last summer.

The penalty, levied by the federal Centers for Medicare & Medicaid Services, was originally $116,150 but was reduced by 35 percent after AMC waived its right to a hearing.

That $75,497 fine is almost two times as much as any of the other federal fines levied on 18 New York nursing homes between Dec. 1, 2008 and Feb. 28, 2009, as reported by the Long Term Care Community Coalition, and advocacy group.

The Aug. 8, 2008 inspection, done by the state in response to a complaint, found nine violations that constituted immediate jeopardy to residents' health and safety, one violation that caused actual harm to residents and three that had the potential for more than minimal harm.

Most of the violations were deemed to affect more than a limited number of residents, and six were ruled to be widespread problems caused by deficiencies throughout the facility and have the potential to affect a large portion of Uihlein's residents.

Since then, AMC has started doing monthly audits and is recruiting more staff for the nursing home.

Most of the violations were tied to the death of an 81-year-old man in the summer of 2008, according to the Statement of Deficiencies issued in November 2008 by the state Department of Health.

The man was admitted to Uihlein from AMC's main hospital in Saranac Lake. An order from the hospital prescribing 0.125 milligrams of Xanax, an anti-anxiety drug, every two hours was mistakenly transcribed as 1.25 mg every two hours, according to the document.

The resident was given two 1.25 mg doses of Xanax and fell into a coma that took five hours for nurses to report to a physician.

A clinical pharmacology report for alprazolam, the generic form of Xanax, recommended that elderly people not exceed a dose of 0.75 mg a day "unless higher for functional status."

The DOH report does not specify that the overdose was the cause of death but makes it clear that an overdose was the reason the patient was readmitted to the hospital from Uihlein.

AMC spokesman Joe Riccio could not comment on the specific case due to patient privacy laws, but he said that since that incident, AMC has started doing monthly audits that span a wide range of areas "to make sure that educational efforts we're offering to staff are providing the intended outcome."

He said the audits are reported monthly to the AMC Board of Trustees, and they've shown Uihlein making significant progress. For one thing, Riccio said, Uihlein hired more staff at a recruitment fair last week.

The August inspection was followed by one in November that resulted in nine violations, but none were for actual harm done to residents; they were all deemed to only have a potential for more than minimal harm. None of them were widespread. A December inspection turned up one isolated violation.

LTCCC Executive Director Richard Mollot said that studies have found that inspectors often don't find the worst problem.

"Quite often, it's the tip of the iceberg at a facility," said Mollot.

Riccio noted that AMC self-reported the incident to the DOH and fully disclosed information about it to residents and the families involved at the time.

"We welcome these opportunities for quality improvement, and our number-one goal is resident safety and enhanced quality of life," said Riccio.



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