Vista Care Center Of Milan

Penalty

No penalty information released

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 report allegations of abuse and neglect related to the suspected administration of medications without physician orders. Multiple staff members observed an LPN pre-pouring Tylenol PM and melatonin into medication cups for residents, despite no residents having orders for these medications. Staff statements indicated that the LPN routinely prepared these medications in advance and that concerns were reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). However, there was no documentation that these allegations were investigated at the time they were reported. Further review revealed that the incidents were not reported to the state agency as required by facility policy and federal regulations. The ADON and DON were both made aware of the allegations, but failed to initiate a thorough investigation or notify the Administrator in a timely manner. There was no evidence of resident or staff interviews, resident assessments, or monitoring for potential adverse medication reactions related to the alleged incidents. The facility's own policies required immediate reporting and investigation of such allegations, but these procedures were not followed. The failure to report and investigate these allegations had the potential to affect 38 residents residing on one unit. The facility census at the time was 87. The Administrator confirmed that the incidents were not reported to the state agency and that there was no documentation of a completed investigation, including interviews or assessments of potentially affected residents.

Penalty

No penalty information released

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 investigate allegations of abuse and neglect related to the administration of Tylenol PM without physician orders on two separate occasions. On the first occasion, a nurse was observed pre-pouring Tylenol PM and melatonin into medication cups for multiple residents, despite no physician orders for these medications. This incident was reported to the Assistant Director of Nursing (ADON), who in turn notified the Director of Nursing (DON), but no investigation was documented, and the allegations were not reported to the state agency as required by facility policy. The nurse in question continued to work on the unit for several days following the initial report. A second incident involved another nurse observing the same LPN preparing and placing Tylenol PM in medication cups for several residents. The nurse took photographs and reported the incident to the ADON, who removed the medication from the cart but did not ensure a thorough investigation or resident monitoring. Interviews with staff and residents revealed that some residents recalled receiving Tylenol PM without an order, while others were unaware. There was no documentation of resident assessments, monitoring for adverse reactions, or pharmacy notification. The facility's own policies required immediate reporting, thorough investigation, and resident assessment, none of which were completed. The deficiency affected up to 38 residents on one unit, many of whom had complex medical and psychiatric diagnoses, including diabetes, bipolar disorder, schizophrenia, and anxiety. Despite multiple staff members reporting concerns about the LPN's medication practices, facility leadership failed to conduct a comprehensive investigation, interview all potentially affected residents and staff, or document any monitoring or assessment for possible adverse effects. The lack of action and documentation directly violated the facility's abuse prohibition and medication administration policies.

Penalty

No penalty information released

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

A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, diabetes, and a right leg amputation was not properly reevaluated for transfer assistance after being unable to use a prosthetic leg due to a blister and improper fit. Despite a physician order discontinuing the use of the prosthesis and a subsequent order for mechanical lift transfers, there was no documentation that the resident’s transfer status was reassessed when the prosthesis was removed. Staff continued to use manual transfer methods without a gait belt or walker, contrary to the care plan and physician orders, and did not consult therapy for updated transfer recommendations. The resident experienced a fall during a transfer attempt by two CNAs who did not use a mechanical lift or gait belt, and involved the resident’s roommate in the process. The fall was not immediately reported to nursing staff as required. Instead, the CNAs attempted to conceal the incident, instructing each other and the resident not to report it. The fall only came to light two days later when another CNA reported it to a nurse, prompting a delayed assessment and notification of the nurse practitioner. There was no immediate post-fall assessment or thorough investigation at the time of the incident. Interviews and record reviews revealed that staff were unclear about the resident’s current transfer needs and failed to follow established protocols for safe transfers and fall reporting. The facility’s policies required prompt reassessment after a change in condition, use of appropriate transfer equipment, and immediate reporting and investigation of falls. These procedures were not followed, affecting the resident involved and potentially impacting other residents on the same units.

Penalty

No penalty information released

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 medications were administered per physician orders and did not assess or monitor for potential medication interactions and adverse effects. Two residents with intact cognition and multiple diagnoses, including diabetes, bipolar disorder, schizophrenia, and hypertension, were found to have received or potentially received Tylenol PM without a physician order. Review of medical records showed that neither resident had an order for Tylenol PM during the period in question, yet staff statements and interviews indicated that an LPN was observed pre-pouring Tylenol PM and Melatonin into medication cups for multiple residents, regardless of whether there was a physician order. Multiple staff members reported witnessing the LPN preparing and distributing Tylenol PM to residents without verifying current orders. Statements revealed that the LPN routinely pre-poured medications, including Tylenol PM, and placed them in medication cups before checking for new orders. The LPN admitted to preparing the medications in advance for convenience and stated that any unused Tylenol PM was returned to the bottle at the end of the medication pass. However, other staff and resident interviews indicated that some residents did receive Tylenol PM, with at least two residents recalling being given two Tylenol PM tablets, which was not in accordance with any physician order at the time. The facility's investigation into the incident was incomplete. There was no documentation of pharmacy notification, resident assessments, or monitoring for adverse reactions. Not all potentially affected residents or staff were interviewed, and there was no evidence of systematic monitoring or assessment following the allegations. The facility's own policy required medications to be administered only after confirming orders and to observe and document resident reactions, but these procedures were not followed. The incident was not reported to the state agency as required, and the lack of thorough investigation and documentation was confirmed by the current DON and Administrator.

Penalty

No penalty information released

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 timely reporting of a potential incident of physical abuse involving a resident with severe cognitive impairment and multiple diagnoses, including COPD, type II diabetes, and schizoaffective disorder. The incident occurred when a CNA, following instructions from an LPN, took the resident outside for re-direction due to disruptive behavior during a New Year's celebration. The resident was dressed appropriately for the weather, and the re-direction was brief, lasting two to three minutes. However, another CNA, who witnessed the incident, believed the action was inappropriate and potentially abusive but delayed reporting it due to fear of retaliation. The CNA eventually reported the incident to another nurse on January 17, who then informed the Social Service Director. An investigation was launched and concluded on February 14, finding the abuse allegations unsubstantiated. Despite this, the facility did not report the incident to the state agency or law enforcement, as they deemed it unsubstantiated and in line with the resident's care plan, which included going outside as a form of re-direction. The facility's policy on abuse, neglect, and exploitation requires immediate reporting of allegations to the Administrator or designee, with an investigation to follow. The policy also emphasizes training staff on appropriate interventions and reporting procedures without fear of reprisal. The deficiency was identified as non-compliance under a specific complaint number, highlighting the failure to adhere to the facility's abuse policy and timely reporting requirements.

Penalty

No penalty information released

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 accurate transcription of physician orders and proper medication administration for two residents. Resident #61, who has severe cognitive impairment and multiple psychiatric diagnoses, did not receive the prescribed medication Austedo for Huntington's disease due to a transcription error by an LPN. The LPN mistakenly entered the order into another resident's medical record, resulting in Resident #61 not receiving any doses of Austedo in December 2024. This error was confirmed by the Director of Nursing during a quality assurance meeting. Resident #29, diagnosed with schizoaffective disorder and other medical conditions, was incorrectly administered Austedo due to a transcription error. The resident, who is cognitively intact and on hospice care, received four doses of Austedo despite not having Huntington's disease. The resident frequently refused medications, and the error was confirmed by the Director of Nursing. The facility's Medication Administration Policy and Procedures require medications to be administered according to valid physician orders, which was not adhered to in these cases.

Penalty

Inspection fine: $12,834

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 provide adequate supervision to prevent the elopement of a resident at risk for elopement, residing on a secured unit. The incident involved a resident with diagnoses including paranoid schizophrenia, schizoaffective disorder, and chronic obstructive pulmonary disease, who was identified as having intact cognition and a moderate risk for elopement. The resident left the facility without staff knowledge and was missing for over five hours before being identified as missing by the staff. The deficiency occurred when the resident was taken outside for a smoke break by a State Tested Nurse Aide (STNA) and was not accounted for upon returning inside. The staff did not realize the resident was missing until a Registered Nurse (RN) attempted to administer medication and could not locate the resident. It was later discovered that the resident had left through an unlocked gate in the courtyard, which was found open by staff during their search. Interviews with staff and residents revealed that the resident had been seen hopping the fence and that the gate had been left open. The facility's policy required hourly rounds to visually observe residents, which were not conducted, contributing to the resident's ability to elope unnoticed. The resident was eventually found 20 miles away, sitting in a lawn chair at a previous residence, after being transported by a police officer who had encountered him earlier in the day.

Removal Plan

• The DON notified the local police department Resident #69 was missing. A search was initiated with staff in vehicles and on foot searching surrounding areas.
• A Root Cause Analysis was completed by the Administrator, DON, Regional Director of Operation (RDO) #500 and Regional Quality Assurance Nurse (RQAN) #410. A plan of correction was started for the failure of direct care staff on the behavior unit to follow policy and procedure for supervision with outside time.
• The DON initiated a Count In/Count Out form for all residents exiting to the courtyard for supervised smoke breaks. The DON notified the physician, guardian, and residents' sister with guardian approval, Resident #69 was missing.
• The DON/designee began audits for the completion of the Count In/Count Out form for resident smoke breaks. These audits will be completed four times a week, times four weeks.
• The DON began education to all staff regarding elopement, notification, resident supervision during outside times, and the abuse policy. The education was completed.
• Resident #69 arrived back to the facility, returned to the secured unit, and was placed on one-on-one supervision. Licensed Practical Nurse (LPN) #294 completed a head-to-toe assessment of the resident with no major injuries found. Resident #69 was sent to the emergency room (ER) for evaluation and treatment related to the elopement.
• LPN #301 and LPN #351 began to assess all residents for elopement risk with care plans updated. All assessments were completed.
• The Quality Assurance Performance Improvement (QAPI) committee met to review the elopement and develop a plan.
• The DON updated the Elopement book.
• Maintenance Director #299 completed an elopement drill.
• Daily audits were completed by Maintenance Director #299 and/or the 300 Unit nurse of the south and north gates in the courtyard to ensure they were locked. These audits continued.
• Resident #69 was discharged to a sister facility with increased supervision levels.
• Maintenance Director #299 installed sensory alarms on the south and north gates in the courtyard. A motion detector was placed outside of the north gate.
• Maintenance Director #299/designee began audits three times a day until further notice to ensure the south and north gates are latched with alarms and motion detector in working order.
• Maintenance Director #299 educated all staff on checking the gates to ensure they were latched with alarms and motion detector in working order at every smoke break and documenting the check.

Penalty

Inspection fine: $12,834

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 timely procurement and administration of pain medication for a resident, resulting in actual harm. Resident #05, who was admitted with chronic pain and other related diagnoses, had a physician's order for Oxycodone, a narcotic analgesic, which was exhausted on 09/14/24 at 4:00 A.M. The facility did not obtain a new written prescription in a timely manner, leading to the resident not receiving the medication for 91 hours. This delay caused the resident to experience severe pain, rated at 10/10, and necessitated an emergency department visit to obtain a dose of Oxycodone and a short-term prescription. The resident's medical records indicated a history of chronic pain, neuropathy, and other conditions requiring pain management. Despite having a care plan that included administering medications as ordered, the facility did not document any non-pharmacological interventions for pain management. Attempts to contact the resident's outside provider for a new prescription were noted but were unsuccessful, and there were no further attempts documented until after the resident's medication had run out. The facility's Director of Nursing confirmed the delay in obtaining the prescription and acknowledged that the resident went without Oxycodone from 09/14/24 to 09/17/24. Interviews with the resident and staff revealed that the resident had requested to go to the emergency room multiple times due to severe pain. The facility's policy on pain management emphasized the importance of timely communication and documentation between the prescriber and staff, which was not adhered to in this case. The deficiency was investigated under Complaint Number OH00158190, highlighting the facility's non-compliance in managing the resident's pain effectively.

Penalty

Inspection fine: $12,834

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 food was served according to the facility menu and dietary spreadsheet, which had the potential to affect all 86 residents receiving meals. During an interview, a resident expressed concerns about meal portion sizes being too small. A review of the weekly menu indicated that the regular breakfast meal included two slices of toast. However, during meal service, it was observed that the dietary staff member served only one slice of toast per resident. The dietary staff member confirmed this discrepancy, acknowledging that residents were supposed to receive two slices of toast with their breakfast meal.

Penalty

Inspection fine: $12,834

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 safe and sanitary storage of food items in the kitchen, affecting all 86 residents residing in the facility. During an observation of the facility's refrigerator and walk-in cooler, several issues were identified. These included a container of undated and unlabeled sliced cheese, a container of undated and unlabeled baked beans, and two undated and unlabeled cups containing a brown substance. Additionally, there were expired items such as a box of tortilla shells, a box of puff pastry sheets, and a box of burritos delivered in a previous month. A box of tuna was also found with an expiration date that had passed. These findings were confirmed during a concurrent interview with a dietary staff member.

Penalty

Inspection fine: $12,834

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 appropriately isolate residents with communicable diseases and ensure proper use of personal protective equipment (PPE) for residents under transmission-based precautions (TBP). This deficiency was observed in two residents who tested positive for Covid-19 but were not isolated from their Covid-19 negative roommates. Additionally, one of these residents was seen participating in communal activities without wearing a mask, increasing the risk of spreading the infection. The Assistant Director of Nursing (ADON) Infection Preventionist (IP) confirmed that the facility was not following proper cohorting practices and did not provide adequate PPE or isolation instructions to residents who refused to move rooms. The facility also failed to properly disinfect shared glucometers, affecting one resident reviewed for glucometer use. A Licensed Practical Nurse (LPN) was observed cleaning a glucometer with an alcohol swab instead of the required healthcare-grade bleach wipes. The LPN admitted to using alcohol swabs as her usual practice, unaware that it was incorrect. The ADON IP confirmed that glucometers should be disinfected with hospital-grade wipes to prevent the transmission of blood-borne pathogens. Furthermore, the facility did not adhere to enhanced-barrier precautions (EBP) during wound care activities. During a wound assessment, the ADON IP and a Wound Nurse Practitioner (NP) did not wear gowns and failed to change gloves after removing a soiled dressing. The ADON IP acknowledged confusion about EBP requirements and admitted to not following proper infection control techniques. The facility's policy required the use of gowns and gloves for high-contact activities, such as wound care, to prevent infection spread.

Penalty

Inspection fine: $12,834

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 maintain a clean and well-repaired environment for residents on the secured unit, affecting all 32 residents residing there. Observations revealed multiple holes in the drywall throughout the hallways and rooms, with sizes ranging from small fist-sized holes to a large 84-inch by 2-foot hole with exposed insulation. Additionally, the flooring in some rooms was in poor condition, with missing tiles and a persistent urine odor. Interviews with residents and staff confirmed that these issues had been present for some time, with one resident expressing dissatisfaction with the condition of their room and another resident having been moved due to the large hole in the wall. Further observations highlighted unsanitary conditions in shared bathrooms, with missing tiles, dirt buildup, and possible black mold. Housekeeping staff reported difficulties in maintaining cleanliness due to the long-standing disrepair of the facilities. The facility administrator acknowledged the environmental concerns and the lack of documentation for repairs or deep cleaning schedules. The administrator also noted that a resident who had been discharged was responsible for some of the damage, but maintenance was unable to keep up with the repairs. The administrator confirmed that a resident should not have been placed in a room requiring repairs.

Penalty

Inspection fine: $12,834

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 residents were treated with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who was observed yelling loudly in the presence of residents during a smoke break. The CNA, who had worked 78 hours in the past week, was venting her frustrations to the residents, which made them uncomfortable. This behavior was confirmed by interviews with the CNA and two residents who witnessed the outburst. The Director of Nursing (DON) and the Administrator acknowledged that such interactions were not appropriate or respectful. Additionally, the facility did not maintain the dignity of residents with indwelling urinary catheters by failing to cover the drainage bags. Resident #68, who had a suprapubic catheter, was observed multiple times with an uncovered urinary drainage bag, visible from the doorway. This was confirmed by a CNA who was unsure why the bag was not covered, despite the facility's policy requiring it to be covered for privacy. Resident #68 later confirmed that a staff member eventually provided a cover for the bag, which he appreciated. Similarly, Resident #41, who also had an indwelling urinary catheter, was observed with an uncovered drainage bag on several occasions. The resident expressed a preference for the bag to be covered, especially when in public areas, to prevent it from getting caught in the wheelchair wheels. The facility's policy mandates that urinary drainage bags be covered to maintain residents' dignity, but this was not consistently followed, as confirmed by interviews with nursing staff and the DON.

Penalty

Inspection fine: $12,834

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 notify the residents' representatives and physicians of positive COVID-19 test results for three residents, which was identified during a review of infection control practices. Resident #23, who had paranoid schizophrenia, depression, and asthma, tested positive for COVID-19 during routine weekly testing. Despite this, there was no documentation in the medical record of the positive test result, nor was there any notification to the resident's guardian or physician. Similarly, Resident #76, with diagnoses including traumatic brain injury and schizophrenia, also tested positive for COVID-19, but the facility did not document the result in the medical record or notify the guardian or physician. Additionally, Resident #53, who had dementia and chronic atrial fibrillation and was under hospice care, tested positive for COVID-19. The facility again failed to document the positive test result in the medical record and did not notify the resident's guardian or physician. An interview with the Assistant Director of Nursing and Infection Preventionist confirmed the lack of documentation and notification for all three residents. The facility's policy on status change in resident condition requires prompt notification of the resident, attending physician, and responsible party, which was not adhered to in these cases.

Penalty

Inspection fine: $12,834

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 residents met the criteria to be admitted to and reside on the secure unit, affecting one resident who was reviewed for involuntary seclusion. The resident, who had diagnoses including neuropathy, muscle weakness, lack of coordination, and anxiety, was admitted to the secure unit due to a lack of available beds elsewhere, despite having intact cognition and being assessed as a low elopement risk. The resident's care plan did not include any information related to the secure unit, and there were no physician orders or documentation justifying the placement on the secure unit. The resident was not informed of her ability to leave the secure unit or given the access code to do so, which was confirmed by both the resident and the Director of Nursing (DON). The DON acknowledged that the resident was placed on the secure unit due to bed availability and was not provided with the door code or informed of her right to leave the unit. This oversight resulted in the resident feeling as though the secure unit was akin to a prison, as she was not made aware of her autonomy to leave the unit at will.

Penalty

Inspection fine: $12,834

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 comprehensive care plans for two residents, leading to deficiencies in addressing their needs. Resident #72, who was admitted with conditions including a left femur fracture, COPD, muscle weakness, and pneumonia, had an incomplete care plan. The care plan lacked interventions for smoking, activities of daily living, medication or diagnosis-specific monitoring, discharge planning, and code status. Additionally, the resident exhibited behaviors such as following a female resident and making inappropriate comments, which were not addressed in the care plan. The MDS Coordinator acknowledged the oversight, attributing it to a high volume of admissions at the time. Resident #49, admitted with multiple diagnoses including hypertension, dementia, and bipolar disorder, was identified as a fall risk. Despite this, the care plan did not effectively implement interventions to prevent falls. The resident experienced multiple falls, and observations revealed the absence of non-skid strips, which were ordered by a physician to prevent sliding. The facility's policies on fall management and care planning were not adhered to, as evidenced by the lack of necessary interventions and incomplete care plans.

Penalty

Inspection fine: $12,834

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 adhere to the food preferences of three residents, as observed during meal services. Resident #29 and Resident #62 were both supposed to receive ice cream with their lunch meal on 09/30/24, as indicated on their meal tickets. However, neither resident received ice cream because the facility was out of stock. This was confirmed by Dietary Aide #348 during an interview, who acknowledged the absence of ice cream and the failure to provide it to the residents as per their preferences. Additionally, Resident #80's meal ticket indicated a dislike for rice, yet rice was served to them during the lunch meal on 09/30/24. This was verified by both DA #348 and Dietary [NAME] #343. Furthermore, on 10/07/24, it was observed that Resident #80 did not like omelets and was not offered an alternative for breakfast, as the facility only provided alternatives for lunch and dinner. This lack of accommodation for Resident #80's preferences was confirmed by DC #344, who stated that the breakfast menu was set without alternatives.

Penalty

Inspection fine: $12,834

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 report a resident elopement to the state agency, which was a deficiency identified during the survey. Resident #69, who had diagnoses including paranoid schizophrenia, schizoaffective disorder, and chronic obstructive pulmonary disease, was residing in a secured unit due to his conditions, which included agitation and exit-seeking behaviors. Despite being at moderate to high risk for elopement, the resident managed to leave the facility on 09/15/24. The resident was later found and returned to the facility, showing no signs of distress but with an abrasion on the right forearm. He was placed under one-on-one supervision and sent to the hospital for evaluation. The incident was not reported to the state agency as required by the facility's policy. The LPN on duty realized the resident was missing when he did not show up for medication and notified the DON. However, the Administrator did not report the elopement to the state agency, believing it did not meet the criteria for reporting. The facility's policy mandates that all alleged violations, including elopements, be reported to the state agency within specified timeframes, which was not adhered to in this case.

Penalty

Inspection fine: $12,834

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 medications were administered as ordered for Resident #291, who was admitted with diagnoses including alcoholic cirrhosis of the liver, suicidal ideations, and major depression. A telephone order from a nurse practitioner on 09/24/24 prescribed Prozac 10 mg daily for anxiety and depression, with a follow-up with psychiatric services. Later that day, a physician increased the Prozac dosage to 40 mg, but the order was not implemented until 09/30/24. The resident did not receive the increased dosage for six days, despite questioning the nursing staff about the delay. Interviews with the resident, the Director of Nursing, and LPN #327 confirmed the delay in administering the correct dosage of Prozac. The LPN acknowledged that the order for the increased dosage was misplaced on a clipboard and not entered into the system until 09/30/24. The facility's policy on medication administration, which mandates that medications be administered as prescribed, was not followed in this instance, leading to a lapse in the resident's treatment plan.

Penalty

Inspection fine: $12,834

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 timely laboratory testing to monitor therapeutic drug levels for psychotropic medications was completed as ordered for a resident with schizophrenia, drug-induced parkinsonism, and lack of coordination. The resident had orders for Lithium Carbonate and Divalproex Sodium, with specific instructions for regular monitoring of lithium and valproic acid levels. However, laboratory results from March and September indicated low lithium levels, and there was no evidence that these results were reported to the psychiatric provider. Additionally, the psychiatric progress notes did not reflect recent laboratory results, indicating a lapse in communication and monitoring. Interviews with facility staff revealed a lack of clarity and consistency in the process for ordering and communicating laboratory tests. An LPN was unsure of the procedure for lab testing, while the ADON confirmed that multiple laboratory tests for the resident's therapeutic drug level monitoring had been missed. The facility's policy required nurses to enter lab orders into the lab computer and report results to the physician or nurse practitioner, but this process was not followed, leading to the deficiency.

Penalty

Inspection fine: $12,834

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 provide a resident with physician-ordered adaptive equipment for meals, specifically a handled cup for liquids. This deficiency affected a resident who had medical diagnoses including muscle weakness, lack of coordination, and neuropathy, which made it difficult for her to grasp cups and glasses. Despite a physician's order for a handled cup dated 07/22/24, observations on multiple occasions revealed that the resident did not have access to the handled cup during meals. Instead, she was provided with a styrofoam cup without a lid, which she found difficult to use due to her hand limitations. Interviews with the resident and staff confirmed the absence of the handled cup, and the resident expressed difficulty in drinking from the provided cups, sometimes resulting in spills. A CNA mentioned that the handled cup was supposed to come from the kitchen on meal trays, but it was not typically kept in the resident's room for use between meals. The Director of Nursing acknowledged that the facility did not have an order for providing adaptive equipment but stated that they would follow written physician's orders.

Penalty

Inspection fine: $12,834

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 complete and accurate medical records for three residents who tested positive for COVID-19. Resident #23, diagnosed with paranoid schizophrenia, depression, and asthma, tested positive for COVID-19 during routine weekly testing. However, there was no documentation of this positive test result in the resident's medical record, nor was there any evidence that the resident's guardian or provider had been notified. Similarly, Resident #76, with diagnoses including traumatic brain injury, schizophrenia, and delusional disorder, also tested positive for COVID-19, but this was not documented in their medical record, and no notification was made to the guardian or provider. Additionally, Resident #53, who had dementia, chronic atrial fibrillation, and muscle weakness, and was under hospice care, tested positive for COVID-19. Like the other two residents, there was no documentation of the positive test result in the medical record, and no notification was made to the guardian or provider. The Assistant Director of Nursing and Infection Preventionist confirmed the lack of documentation and notification for all three residents. The facility's policy required licensed nurses to record any changes in a resident's medical condition or status, which was not adhered to in these cases.