Cumberland Health And Rehab

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the QAPI committee developed interventions, including training, to systemically address protective measures following an incident of visitor-to-resident sexual abuse. On 12/21/2023, a CNA witnessed a male visitor with his hand down a resident's shirt, fondling the resident's breast. The facility did not have a policy or procedure for screening visitors or providing supervision during visits. The male visitor was later identified as a registered sex offender. The QAPI committee did not identify all causal factors and failed to develop and implement a corrective action plan to address these issues comprehensively. Additionally, the facility failed to address the issue of a resident keeping vape devices in their room. On 03/04/2024, staff found multiple vape devices in the resident's room. It was revealed that the DON had found a vape in the resident's room on two separate occasions weeks prior, and no actions were taken. Multiple staff indicated that the resident would sleep with a vape device on their chest and charge the devices at bedside using a cell phone charger. The facility did not have policies and procedures in place to address resident vaping, including where vaping was prohibited, safe storage of vape devices, and safe charging of the vape devices. The QAPI committee's failure to thoroughly review all factors and implement interventions had the potential to affect all 86 residents. The facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate jeopardy began on 12/21/2023 and continued until 06/02/2024 when the facility implemented corrective action to prevent recurrence.

Removal Plan

• Education was provided to the Nursing Home Administration by the Director of Operations Officer regarding QAPI resources, how to analyze and self-identify potential issues, tools, and programming available to assist in self-identifying issues in the facility that require a root cause analysis, thorough investigation, and process changes with ongoing monitoring.
• All members of QAPI, the Administrator, DON, Medical Director, MDS Coordinators, Infection Control Nurse, Maintenance Director, Social Services Director, Dietary Manager, Environmental Services, Therapy Director, Activities Director, Pharmacy Consultant, Medical Records and Scheduling Coordinator were educated by the Director of Operations Office and Corporate Clinical Consultant on the process of self-identify and report issues within the facility. Once self-identification of an issue occurs, the facility is to immediately identify root causes of such issues and complete a thorough investigation that will ultimately lead to correcting process issues and broken systems, monitoring such issues and continually reviewing to ensure continued compliance.
• A full Quality Assurance and Performance Improvement Committee meeting occurred with the Nursing Home Administrator, Director of Nursing, Facility Medical Director, Director of Operations Officer, and Corporate Clinical Consultant to review the center's processes, policies and the citations at hand to ensure all patients were free from abuse incidents and protective measures were in place to ensure safety.
• The QAPI Committee also implemented policies related to vaping and identified safe storage measures, designated smoking areas, and staff responsible for ensuring vapes are charged.
• E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices. Resident use of these devices will not be permitted at the facility.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from sexual abuse by a visitor. In late November or early December 2023, the resident's daughter informed the facility that a male visitor was upsetting the resident and requested that he not be allowed to visit. The staff member advised the daughter to come to the facility to complete paperwork, but the male visitor returned in early December and visited the resident at the nurses' desk. On December 21, 2023, a CNA witnessed the male visitor fondling the resident's breast. The facility did not have a policy or procedure for screening visitors or providing supervision during visits. The male visitor was later identified as a registered sex offender. The facility's noncompliance was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents, resulting in an Immediate Jeopardy (IJ) situation that continued until June 3, 2024, when corrective actions were verified to have been implemented. The facility also failed to protect another resident's right to be free from physical abuse by another resident. On April 14, 2024, one resident accused another of stealing a TV remote and hit the other resident on the left knee. The incident was reported, and the investigation revealed that physical abuse had occurred. The affected resident did not sustain any injuries, but the incident was classified as physical abuse. Additionally, the facility failed to protect a resident with a history of substance abuse from neglect. A CNA gave the resident a medication, Klonopin, from her personal prescription. The facility had not provided training to staff on how to deescalate situations involving residents with substance abuse. The resident had a history of substance abuse, and the facility did not have a care plan in place to address this issue. The CNA was aware that she was not to administer medication to any resident in the facility, and the incident was reported to the local police department, ombudsman, and state authorities.

Removal Plan

• Visitor was immediately removed from the center and resident's safety ensured.
• Administrator reported incident to AP.
• Residents responsible party was notified of the incident and responded to the center.
• Local Law Enforcement Department was notified and responded to the center.
• The facility County Sheriff Department was notified and responded to the center.
• Facility medical director was notified of the incident.
• RI #27 was assessed by charge nurse and no injuries were noted.
• All patients/residents with a BIMS of 8 and above were interviewed by Activities Director and no patient/right reported ever being abused by a staff member, patient/resident or visitor.
• A full body audit was completed by the charge nurse on all patients/residents with a BIMS of 7 and below and no injuries noted.
• Abuse in-services initiated including sexual, physical, verbal, psychosocial, financial, misappropriation of resident's funds, abandonment, and neglect, as well as practices, including reporting requirements, and notifying the Abuse Coordinator/Administrator immediately regarding any allegation of abuse. This abuse education was provided by the director of nursing to all staff, with 126 out of 132 staff educated.
• HH Health Systems Director of Operations provided education to the facility's administrator and Director of Nursing.
• The Director of Nursing provided education to 126 out of 132. This inservice was provided for nurses, certified nursing assistants, department leaders/management, contract therapy services, housekeeping services and dietary services. All staff will be in-service prior to start of shift.
• All staff that did not receive the in-service will be denied access from clocking into the facility. These staff have been notified either by voice mail or text send to their cellular devices. This notification states that they are not permitted to work until receiving the mandated abuse education per the Director of Nursing.
• The Abuse Coordinator will hold weekly in services on reporting and identifying abuse to the Department Managers for four weeks, then monthly thereafter. The Department Manager will provide in-services on reporting and identifying abuse with their staff weekly for four weeks, then monthly thereafter. An attendance sheet will be maintained on each in-service to ensure full staff compliance. All attendance sheets will be given to the Abuse Coordinator/Administrator.
• A Receptionist/Door Greeter position will allow for closer monitoring of visitors to the facility. This position will be occupied 7 days per week for 12 hours per day. The receptionist will be responsible for ensuring guest sign in/out. A Restricted Visitor List of people not allowed in facility will be located at the Receptionist Desk that includes photos, if available, general identification information of unwanted guest. If anyone on the list tries to enter the building, the receptionist will be trained to not allow them to enter the building. If the visitor refuses to comply, the local police department will be notified.
• After hours the front doors will be locked and the charge nurse or designee will be responsible for monitoring entrance into the facility. They will ensure visitors sign into the Guest Registry and screen visitors to confirm they are not on the Resident Visitor List. If the visitor is restricted, the Charge Nurse or designee will inform them they are not permitted in the facility. If the visitor does not comply with leaving premises, the local police will be notified.
• Residents Council meeting conducted provided education to residents on facility abuse policy and reporting process. All patient/residents reported they feel safe at the center.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a system was in place to ensure residents' safety while smoking and to safely store and charge electronic cigarettes or vape devices. A resident was admitted with a history of daily smoking, but the facility did not assess the resident's smoking safety upon admission. The resident was found with multiple vape devices in their room, including instances where the resident slept with a vape device on their chest while it was charging using a cell phone charger, posing a significant safety risk. Despite staff being aware of the resident's possession and use of vape devices, no actions were taken to address the safety concerns, and the facility's smoking policy was not enforced until much later. The facility's smoking policy required all electronic cigarettes to be stored with other smoking materials and indicated that non-compliance would result in a 30-day discharge after two offenses. However, the facility did not issue a 30-day discharge until several weeks after the resident was found with vape devices. Additionally, the facility failed to complete smoking safety assessments for multiple residents, including the resident in question, and did not develop appropriate interventions for residents assessed as not safe to smoke. This lack of proper assessment and intervention put multiple residents at risk. Interviews with staff revealed that the Director of Nursing (DON) and other staff members were aware of the resident's possession and use of vape devices but did not take appropriate actions to ensure safety. The DON admitted to finding vape devices in the resident's room on two separate occasions but did not follow the facility's smoking policy. Other staff members also observed the resident with vape devices and charging them unsafely but did not report these observations or take corrective actions. The facility's failure to properly assess, monitor, and intervene in residents' smoking and vaping activities led to a determination of immediate jeopardy and substandard quality of care.

Removal Plan

• All smoking material, to include pipes cigars, vapes, snuff, etc. were removed from patient/resident possession and locked on secure cart monitored by nurse.
• All smoking paraphernalia will remain locked on cart and only utilized during designated smoking times.
• E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices. Resident use of these devices will not be permitted at the facility.
• All smoking assessments and care plans updated by the charge nurse for all patients and residents that identify as a smoker. To include patients and residents that utilize electronic smoking devices. Electronic smoking devices identified as any product containing or delivering nicotine or any other substance that can be used by a person for the purpose of inhaling vapor or aerosol from the product.
• All patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgement of center revised policy and 30-day discharge issuance should policy be violated.
• All staff in-service regarding the centers revised smoking policy and procedure to include transitioning to a smoke-free campus for all new admissions, daily smoking schedule, safe smoking interventions to be utilized, and facility action plan should the centers revised smoking policy be violated.
• Resident council meeting facilitated by the Activities Director to inform all patients and residents of new smoking policy including smoke-free campus for all new admissions.
• Smoke detectors were installed in all patient and resident rooms that a current smoker reside in.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive smoking policy that included guidelines for vaping, storage, charging, and noncompliance. This deficiency affected multiple residents, including one resident who was found with multiple vape devices in their room. The facility's smoking policy did not address vaping, and staff were not trained on how to handle vaping devices, leading to unsafe conditions. The resident's Smoking Safety Evaluation (SSE) form was incomplete and not properly updated, and the resident was found vaping in their room multiple times, including while asleep with the vape on their chest. Interviews with staff revealed that they were aware of the resident's vaping but did not take appropriate action because the facility's policy did not provide clear guidelines for handling vaping devices. The Director of Nursing (DON) and other staff members admitted that they did not follow the same guidelines for vaping as they did for smoking. The DON had removed vape devices from the resident's room on multiple occasions but did not implement further measures to ensure compliance with safety protocols. Other residents who smoked also had incomplete or improperly filled out SSE forms, and their care plans did not include necessary interventions to ensure their safety while smoking. Staff interviews indicated a lack of training on how to complete the SSE forms and assess smoking safety. The facility's failure to address vaping and smoking safety comprehensively had the potential to affect all residents with a desire to vape or smoke, posing a significant risk to their safety.

Removal Plan

• All smoking assessments and care plans updated by the charge nurse for twelve patients and residents that identify as a smoker. To include patients and residents that utilize electronic smoking devices. Electronic smoking devices identified as any product containing or delivering nicotine or any other substance that can be used by a person for the purpose of inhaling vapor or aerosol from the product.
• The nurses conducted the Smoking Assessments with residents who identified themselves as a smoker. The nurse identified risks and interventions that would be needed due to safety concerns for the resident. These assessments are entered into the facility's Electronic Medical Record (EMR) where the assessment outcomes are available for Social Services to develop Smoking Safety Care Plans. Social Services will print the Smoking Assessment and the Smoking or Smokeless Tobacco Care Plan to forward to the Activities Director.
• The Activities Director will maintain a Smokers and Smokeless Tobacco binder for the smoking area storage cart. This binder includes a list of residents who use tobacco products, smoking and smokeless, the smoking assessment, and the appropriate tobacco-use care plan. The Smoking and Smokeless Tobacco Binder will be stored in the locked storage cabinet at the resident's smoking area. This binder, along with the assessments and care plans provide the Smoke Break Supervisors direction on the care of the resident while participating in the tobacco use scheduled activity. Smoking supervisors are to adhere to the recommended smoking interventions and facility's smoking policy during all smoke breaks.
• All patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgement of center policy and 30 day discharge issuance should policy be violated.
• All staff in-serviced regarding the centers revised smoking policy and procedure to include transitioning to a smoke free campus for all new admissions, including smokes tobacco, daily smoking schedule, safe smoking interventions to be utilized and facility action plan should the centers smoking policy be violated.
• E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices. Resident use of these devices will not be permitted at the facility.
• Resident council meeting facilitated by the Activities Director to inform all patients and residents of new smokefree campus for all new admissions.
• Smoke detectors installed in all patient and resident rooms that a current smoker resides in.
• Corporate Clinical Consultant educated the Director of Nursing regarding instructions on how to complete the Safe Smoking Assessment form for all patients and residents. The Director of Nursing was informed that all Licensed Practical Nurses and Registered Nurses can complete and interpret the Safe Smoking Assessment and implement safe smoking interventions. The Director of Nursing implemented education with all Licensed Practical Nurses and Registered Nurses with instructions on how to complete and interpret the Safe Smoking Assessment.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement policies and procedures for residents who vape, specifically addressing safe storage, safe charging, and designated vaping areas. Staff discovered multiple vape devices in a resident's room on several occasions, with the resident often found sleeping with a vape device on their chest and charging the devices at bedside using a cell phone charger. Despite these findings, no actions were taken to address the issue, and the facility lacked a specific policy on vaping, which was confirmed by the Director of Nursing (DON) and the Former Administrator (FADM). The DON admitted to verbally warning the resident but did not document the incidents or take further action. The DON and FADM both acknowledged the need for a policy to address vaping, similar to the existing smoking policy, to ensure staff knew how to handle such situations. The DON was unaware of the proper charging guidelines for vape devices, which posed an electrical safety concern. The FADM confirmed that the facility had never trained staff on vaping or how to charge vape devices safely. Both the DON and FADM emphasized the importance of following the manufacturer's guidelines for charging to prevent potential fire hazards. The current Administrator (ADM) also confirmed the lack of policies and procedures specific to vaping and acknowledged the responsibility to ensure resident safety and policy implementation. The ADM stated that the facility should have reviewed and revised their policies and procedures to address the issues identified with the resident's vaping behavior. The absence of a specific vaping policy left staff without clear guidelines on how to manage residents who vape, potentially compromising resident safety.

Removal Plan

• The new Nursing Home Administrator was educated on role, job description and available tools and resources to effectively administer nursing facility operation by the Chief Operations Officer.
• The Director of Operations Officer will provide oversight of facility administration with weekly 1:1 interaction reviewing the Nursing Home Administrator ability to oversee operations and develop and implement policies and procedures, staffing and the administration of medications by staff to ensure residents are receiving the highest level of care possible.
• Meetings will include a review of any current or ongoing Quality Assurance and Performance Improvement minutes, to validate the Administrator's ability to effectively self-identify new issues and validate available tools are being used to administer the facility in the highest possible manner.
• The Chief Operations Officer and Administrator will have these encounters to ensure education is understood.
• The plan of correction will be reviewed weekly to ensure all the audits are completed and issues are identified for four weeks and/or until substantial compliance is achieved.
• Monthly QAPI meeting will be conducted and attended by the Chief Operations Officer and Clinical QA RN for a period of three months to ensure compliance is sustained.
• E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no residents identified as using these devices.
• Resident use of these devices will not be permitted in the facility.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Governing Body failed to provide oversight to ensure policies and procedures were developed and implemented for residents who vape, specifically addressing safe storage and charging. On multiple occasions, staff found vape devices in a resident's room, with the resident often sleeping with a vape device on their chest and charging the devices at bedside using a cell phone charger. Despite these findings, no actions were taken to address the issue, and the facility did not have a specific policy for vaping, only a general policy for smoking and tobacco use. The Director of Nursing (DON) had previously found a vape in the resident's room on two separate occasions weeks prior, but no measures were taken to mitigate the risk. The Director of Operations (Care Center) confirmed that he was responsible for the overall safety of the residents and ensuring policy and procedures were implemented. However, he was not made aware of the incidents with the vapes until recently and acknowledged that the facility lacked a specific policy for vaping safety. The facility's noncompliance with the requirements of participation was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) began when the vape devices were first found and continued until corrective actions were implemented. The deficiency was cited as a result of a Facility Reported Incident and was related to the State Operations Manual, Appendix PP, 483.70 Administration, at a scope and severity of J.

Removal Plan

• All patients and residents that use nicotine products to include electronic smoking devices and smokeless tobacco signed acknowledgment of update center policy and 30-day discharge issuance should policy be violated
• All staff in-serviced regarding the centers smoking policy and procedure to include transitioning to a smoke free campus for all new admissions, daily smoking schedule, safe smoking interventions to be utilized, and facility action plan should the centers smoking policy be violated
• E-cigs, vapes and other electronic nicotine distribution systems were reviewed with residents, no resident identified as using these devices. Resident use of these devices will not be permitted at the facility
• Resident council meeting facilitated by the Activities Director informed all patients and residents of new smoke free campus for all new admissions
• Smoke detectors were installed in all patient and resident rooms that a current smokers resides in

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a behavioral health care plan was developed with person-centered interventions for a resident with documented substance abuse and noncompliance of care. The resident, identified as having stimulant dependence, tested positive for cannabinoids and had a history of non-compliance with the facility's smoking policy. Despite these issues, the facility did not develop a behavioral health care plan to address the resident's needs, nor did they train staff on how to handle residents with substance abuse disorders. Interviews with facility staff revealed significant gaps in the implementation of behavioral health policies. The Social Services Director admitted to not utilizing prior diagnoses or behaviors to develop care plans and stated that she had not been trained to handle substance abuse residents. Similarly, the Minimum Data Set Coordinator and the Director of Nursing acknowledged that the facility's behavioral policy lacked clarity and did not provide guidance for developing care plans for residents with substance abuse disorders. Additionally, staff had not received specific training on how to care for such residents. The deficiency was further highlighted by an incident where a Certified Nursing Assistant (CNA) gave a resident Klonopin after being pressured and physically pinched by the resident. This incident, along with the lack of a comprehensive care plan and staff training, underscores the facility's failure to meet the behavioral health needs of its residents, particularly those with substance abuse issues.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff received substance abuse training, which affected a resident with a history of stimulant dependence. The resident, who was cognitively intact, had tested positive for methamphetamines and had a history of visitors bringing illegal drugs. The Social Services Director (SSD) admitted to not being trained in care approaches for residents with substance abuse issues and confirmed that no care plan was developed for the resident's non-compliance. Additionally, a Certified Nursing Assistant (CNA) admitted to giving the resident Klonopin without proper authorization or training, further indicating a lack of staff preparedness to handle substance abuse cases. The Minimum Data Set Coordinator (MDSC) recalled the resident's substance abuse history but did not ensure that the facility assessment was updated to address this issue. The Administrator acknowledged that the facility assessment should have been revised to include substance abuse, and appropriate care, resources, and education should have been provided. This deficiency highlights a significant gap in staff training and facility preparedness to manage residents with substance abuse histories, leading to inadequate care planning and potential safety risks.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that their facility-wide assessment addressed substance abuse, smoking, and vaping. This deficiency was identified during the investigation of a Facility Reported Incident. The facility's most current assessment did not identify the need for staff competencies regarding substance abuse, which had the potential to affect all 86 residents. Specifically, the assessment did not include provisions for the care, resources, and education necessary for residents with a history of substance abuse or those who smoke or vape. A resident admitted to the facility had diagnoses including Paraplegia, Muscle weakness, and Stimulant Dependence. The resident's medical records indicated a high level of dependence and a history of smoking ten cigarettes per day. Additionally, the resident had tested positive for methamphetamines, amphetamines, and meth at the transferring hospital, which also reported that visitors had brought illegal drugs to the hospital. The facility administrator acknowledged that the facility assessment should have been revised to address substance abuse and smoking to ensure proper care and safety provisions.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Section J of the Minimum Data Set (MDS) assessments for two residents, identified as RI #80 and RI #286, were accurately coded to reflect tobacco use during the assessment period. RI #80 was admitted with diagnoses including Difficulty in Walking, Muscle Weakness, Lack of Coordination, and Chronic Obstructive Pulmonary Disease. Despite a smoking safety evaluation indicating non-smoker status, an observation revealed that RI #80 had cigarettes and a vape labeled with their name. Additionally, an activities staff member confirmed that RI #80 participated in smoking activities, contradicting the MDS assessment coded for no tobacco use. RI #286, admitted with diagnoses including Paraplegia, Muscle Weakness, and Stimulant Dependence, was also inaccurately assessed. The resident's history and physical from a local hospital indicated a social history of smoking ten cigarettes a day. Despite this, the MDS admission assessment coded RI #286 as a non-smoker. The MDS Coordinator admitted to not asking RI #286 about their smoking habits during the assessment. Further, nursing notes and activity logs confirmed that RI #286 participated in smoke breaks, which was not reflected in the MDS assessment. The Director of Nursing acknowledged the inaccuracies in both residents' MDS assessments regarding tobacco use.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's nebulizer mask was stored in a covered plastic bag as required by their policy. The resident, who was admitted with a diagnosis of Hypertensive Heart Disease with Heart Failure, had physician orders for Ipratropium-Albuterol to be administered via nebulizer every six hours as needed for shortness of breath or cough. On two separate occasions, the nebulizer mask was observed uncovered and not stored in a plastic bag, which is a violation of the facility's policy on oxygen administration. Interviews with the staff, including a Registered Nurse and the Director of Nursing, confirmed that the nebulizer mask should have been stored in a plastic bag when not in use to prevent contamination and potential infection. The failure to follow this protocol was identified as an infection control issue, as the uncovered mask could harbor bacteria. This deficiency affected the resident who required respiratory care and was sampled for this specific observation.

Penalty

Inspection fine: $238,745

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Certified Nursing Assistant (CNA) did not administer her personal prescription of Klonopin to a resident. The incident was reported to the State Survey Agency, which revealed that CNA #19 had given her personal prescription of Klonopin 0.5 mg to Resident Identifier (RI) #286. This action was not in accordance with the facility's medication administration policy, which mandates that medications are to be administered by licensed nurses or other legally authorized staff as ordered by a physician. The CNA admitted to giving the medication without reviewing the resident's medication orders and acknowledged that she was not trained to administer medications. The resident, RI #286, had diagnoses including paraplegia, muscle weakness, and stimulant dependence. The resident's admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 15, suggesting intact cognitive function. There was no physician order for Klonopin for this resident. The incident came to light when another CNA, CNA #18, reported that the resident had disclosed receiving Klonopin from CNA #19. The facility's timeline documented that CNA #19 admitted to giving the medication one time and was aware that she should not have done so. Interviews with the involved CNAs and the Medical Director highlighted the potential harm from such an action, including drug interactions and allergic reactions. The Medical Director emphasized the risks associated with a CNA administering a controlled substance like Klonopin. The facility's policy on medication administration clearly states that only licensed nurses or legally authorized staff should administer medications, and this policy was not followed in this instance.