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Buffalo nursing home fined $47,827 over medication mistake

The federal government has fined a Buffalo nursing home $47,827 after it incorrectly administered insulin injections to a resident.

State Health Department investigators determined the failure to properly care for the Humboldt House Rehabilitation and Nursing Center resident resulted in "actual harm."

The fine imposed by the Centers for Medicare and Medicaid Services was the sixth-largest nursing home fine in the state in 2018 and the largest in the Buffalo area.

When a diabetic woman was returned to Humboldt House from a hospital, a Feb. 13, 2018, hospital discharge report told the nursing home staff: "PLEASE AVOID GIVING THIS PATIENT INSULIN," in capital letters.

Several days earlier, the woman, who was not identified in a Health Department report, had ended up in the hospital after she was twice found unresponsive in her bed and had to be revived with medications and fruit juice.

Despite the discharge summary, the Health Department inspection report said that the nursing home's medical director, a physician, signed an order to administer insulin to the woman. The doctor blamed a nurse for inaccurately reading to him the resident's hospital discharge directives, apparently in a phone call, according to the Health Department report.

"I do not know why the insulin was ordered if the discharge summary had to stop it. The nurse must have misread the orders to me. I usually try to read the discharge summaries from the hospital when I come in and see the resident," the physician stated, according to the inspection report, adding he is required to see a resident within 48 hours after returning from the hospital.

In this case, the doctor said he did not follow through on his practice of reading the discharge summary when he examined the woman.

"I do not know why I did not address the recommendations in my history and physical ... or discontinue the insulin," the doctor stated to a Health Department investigator.

In its broader failure to properly monitor diabetic residents, Humboldt House officials stated they have subsequently provided training to the nursing staff to make sure glucose testing is conducted when diabetic individuals are admitted. The officials also told the state investigator that the nurse who inaccurately read the hospital discharge summary to the doctor had been disciplined.

But the director of nursing said, "The doctor should have looked at the discharge summary. It is expected the doctors read the discharge summary."

Defending Humboldt House, located at 64 Hager St., administrator Isaac T. Williams said the resident cited in the insulin mishap was later successfully discharged from the facility to her home.

Williams also said that the fine pertained to only one resident and when the state Health Department revisited the facility, Humboldt House "was found to be in substantial compliance with all regulatory requirements."

Humboldt House has a one-star overall rating, or "much below average," from the Centers for Medicaid and Medicare Services.

In the past 12 years, only three other nursing homes in Erie and Niagara counties have had larger total fines than Humboldt House. Those three are Emerald North Nursing and Rehabilitation Center, $112,647; Safire Rehabilitation of Southtowns, $91,925; and Comprehensive Rehabilitation and Nursing Center in Williamsville, $60,000.

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