Bishop Rehab & Nursing Center: Medication Failures NY
SYRACUSE, NY - A federal inspection at Bishop Rehabilitation and Nursing Center uncovered serious lapses in medical communication that placed residents at immediate risk of severe harm, including failures to notify healthcare providers about dangerously low blood sugar levels and missed critical medications.
Critical Medication Management Failures Put Residents at Risk
The July 2024 inspection revealed multiple instances where the facility's failure to communicate with medical providers created dangerous situations for vulnerable residents. In one case, Resident #37 went without their prescribed Lyrica medication for two full days - from the morning shift on June 22 through the morning shift on June 24, 2024.
The gap occurred because the facility had run out of the resident's ordered medication but failed to notify the prescribing provider about the shortage. Lyrica, the brand name for pregabalin, is commonly prescribed for nerve pain and seizure disorders. Sudden discontinuation of this medication can trigger withdrawal symptoms including anxiety, sweating, nausea, and in severe cases, seizures.
This violation was classified as immediate jeopardy, the most serious level of deficiency that indicates a situation likely to cause serious injury, harm, or death to residents. The Centers for Medicare & Medicaid Services requires nursing homes to maintain adequate medication supplies and have protocols in place to prevent such interruptions in care.
Life-Threatening Blood Sugar Crisis Goes Unreported
Perhaps even more alarming was the facility's handling of a laboratory emergency involving Resident #153, who had dangerously low blood glucose levels reported by the lab on June 22, 2024. Despite receiving this critical laboratory result, nursing staff failed to notify the resident's medical provider.
Severe hypoglycemia represents a medical emergency that can rapidly progress to unconsciousness, seizures, brain damage, and death if left untreated. Blood glucose levels below 70 mg/dL require immediate intervention, and levels below 54 mg/dL are considered critically low and require urgent medical attention.
The failure to communicate this laboratory finding to the provider meant that no immediate medical intervention was ordered or provided. This violation was also classified as immediate jeopardy due to the likelihood of serious injury, serious harm, or death that could result from untreated severe hypoglycemia.
Standard protocols in nursing facilities require immediate notification of providers for any critical laboratory values. Most facilities have established "critical value" lists that mandate provider notification within 30 minutes of receiving results that could indicate life-threatening conditions.
Six-Month Pattern of Refused Medications Without Provider Assessment
The inspection also uncovered a troubling long-term pattern involving Resident #147, who had been refusing essential medications including heparin, insulin, and laboratory tests for six months. Despite this extended period of medication refusal, the medical provider was never notified and no assessment was conducted by a qualified healthcare professional.
Heparin is a critical anticoagulant medication used to prevent dangerous blood clots that can cause strokes, heart attacks, or pulmonary embolisms. Insulin is essential for managing diabetes and preventing complications including diabetic ketoacidosis, which can be fatal. When residents refuse these life-sustaining medications for extended periods, federal regulations require prompt provider notification and assessment.
The resident's right to refuse treatment must be balanced with ensuring they understand the consequences of their decisions. Healthcare providers need to evaluate whether the refusal stems from depression, cognitive impairment, or other treatable conditions that might be influencing the resident's decision-making capacity.