SYRACUSE, NY - Federal inspectors have identified serious medical care violations at Bishop Rehabilitation and Nursing Center following a July 2024 inspection that revealed failures in medication management, physician notification protocols, and resident monitoring that placed multiple patients at immediate risk.
Critical Medication Management Failures Put Residents at Risk
The most severe violation involved a complete breakdown in pain medication management for Resident #37, who went without their prescribed Lyrica for nearly 48 hours. According to the inspection report, the resident did not receive their medication "from the day shift (7:00 AM-3:00 PM) of 6/22/2024 until day shift of 6/24/2024 due to the facility not having the resident's ordered medication and the provider was not notified."
This failure represents multiple systemic breakdowns in basic nursing home operations. Lyrica (pregabalin) is commonly prescribed for neuropathic pain and seizure disorders, conditions that require consistent medication levels to prevent breakthrough symptoms. When pain medications are suddenly discontinued, patients can experience severe withdrawal symptoms, increased pain levels, and in cases where Lyrica is used for seizure control, potentially life-threatening seizure activity.
The inspection findings indicate that the facility failed to maintain adequate medication inventory and compounded this error by not notifying the prescribing physician when the medication was unavailable. Standard nursing home protocols require facilities to maintain sufficient medication supplies and have emergency procedures for obtaining medications when supplies run low. Additionally, federal regulations mandate that physicians be notified immediately when prescribed medications cannot be administered as ordered.
Dangerous Blood Sugar Emergency Goes Unreported
A particularly alarming case involved Resident #153, who experienced a dangerously low blood glucose level that laboratory personnel reported to the facility on June 22, 2024. Despite receiving this critical laboratory result, nursing staff failed to notify the resident's physician, creating what inspectors classified as an immediate jeopardy situation with "likelihood of serious injury, serious harm, or death."
Severe hypoglycemia (low blood sugar) is a medical emergency that can rapidly progress to unconsciousness, seizures, brain damage, and death if not promptly treated. Blood glucose levels below 70 mg/dL require immediate intervention, and levels below 54 mg/dL are considered severely low and potentially life-threatening. When laboratory personnel specifically contact a facility about abnormal results, it indicates the values are critically outside normal ranges and require urgent medical attention.
The failure to notify the physician prevented timely medical assessment and potential adjustment of the resident's diabetes medications. Elderly nursing home residents are particularly vulnerable to hypoglycemic episodes due to irregular eating patterns, kidney dysfunction that affects medication clearance, and the presence of multiple medical conditions that can influence blood sugar control.
Six-Month Pattern of Medication Refusals Ignored
The inspection revealed a concerning pattern with Resident #147, who "refused heparin, insulin, and labs as ordered for a period of 6 months" without any physician notification or medical assessment. This situation represents a fundamental failure in resident care coordination and medical oversight.
Heparin is a blood-thinning medication typically prescribed to prevent dangerous blood clots, while insulin is essential for diabetes management. When residents consistently refuse critical medications, nursing facilities are required to implement intervention strategies, which may include patient education, alternative medication timing, or consultation with physicians about alternative treatments.
The six-month duration of these refusals without medical provider involvement suggests a complete breakdown in care plan monitoring. Federal regulations require that resident care plans be reviewed and updated regularly, particularly when residents are not receiving prescribed treatments. The lack of physician assessment during this extended period prevented evaluation of whether alternative treatments might be more acceptable to the resident while still addressing their medical needs.
Severe Dehydration Case Highlights Monitoring Failures
Resident #528 experienced a significant change in condition that went unaddressed until the situation became severe enough to require hospitalization for dehydration. The inspection found that when staff noted the change in the resident's condition, no qualified professional assessed the resident, the medical provider was not notified, and the resident's representative was not informed.
Dehydration in elderly nursing home residents can develop rapidly and become life-threatening. Early signs include decreased urination, dry mouth, confusion, and weakness - symptoms that trained nursing staff should recognize and address promptly. Severe dehydration can lead to kidney failure, electrolyte imbalances, cardiovascular complications, and altered mental status.
The requirement for qualified professional assessment means that when residents show signs of condition changes, registered nurses or other licensed healthcare providers must evaluate the situation and determine appropriate interventions. The failure to involve qualified staff in this assessment represents a violation of basic nursing care standards and potentially delayed critical medical interventions.
Medical Oversight and Communication Standards
These violations highlight fundamental breakdowns in the communication systems that are essential for nursing home safety. Federal regulations require nursing facilities to have physician notification protocols that ensure medical providers are informed of significant changes in resident conditions, medication issues, and abnormal laboratory results within specific timeframes.
The repeated pattern of failing to notify physicians suggests systemic problems with the facility's communication protocols. Effective nursing home care depends on seamless communication between nursing staff and physicians, as many residents have complex medical conditions requiring ongoing monitoring and frequent medication adjustments.
Industry standards require that nursing facilities maintain 24-hour physician availability for urgent consultations and have clear procedures for when and how to contact medical providers. The failure to follow these protocols not only violates federal regulations but also compromises the fundamental medical oversight that nursing home residents require.
Additional Issues Identified
The inspection narrative references additional concerns related to Activities of Daily Living, though specific details were not fully provided in the available documentation. This suggests the scope of compliance issues at the facility may extend beyond the critical medical care violations that were classified as immediate jeopardy situations.
The classification of these violations as "Immediate Jeopardy" and "Substandard Quality of Care" indicates that inspectors determined the facility's practices created substantial risk of serious injury or harm to residents. This level of citation requires facilities to develop and implement immediate corrective action plans to address the identified deficiencies and prevent similar occurrences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bishop Rehabilitation and Nursing Center from 2024-07-11 including all violations, facility responses, and corrective action plans.
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