Print Inspection: 5FXJ

a. Based on interview and record review, during a site visit conducted on

08/20/24, it was confirmed the facility had not ensured the implementation of

services for 1 of 6 sampled residents (#2). Findings include, but are not limited

to:

During an interview, Staff 1 (ED) indicated there had been an agency staff

member who had neglected to provide required services to Resident 2

including not assisting with the toileting assistance. That staff member had not

abandoned his/her shift but had neglected to provided services, s/he was

immediately put on the "do not return to the facility" list.

A review of Resident 2's progress notes from 08/01/24 through 08/16/24

indicated the following;

 On 08/04/24, Resident has urinated in the hallways twice during the

shift. S/he may need to be toileted more often, check for UTI.

 On 08/05/24, Resident urinated and defecated in the hallways five times

during the shift.

A review of Resident 2's service plan dated 04/03/24, indicated for bladder

management, staff will ensure that resident is dry, clean, and odor free

throughout the shift. Resident has occasional accidents.

It was confirmed the facility had not ensured the implementation of services.

On 08/20/24, the findings were reviewed with and acknowledged by Staff 1

and Staff 2.

Verbal plan of correction: ED will continue to post open shifts with agency and

need agency staff to pick up the shift. ED has "do not returned" the agency

staff who was responsible for ensuring resident to have been changed after

soiling themselves.

b. Based on observation and interview, during a site visit conducted on 08/20/24,

it was confirmed the facility failed to have service plans readily available to

staff. Findings include, but are not limited to:

During an interview, Staff 1 (ED) indicated the care staff access the current

service plans from the service plan binders in the medication room. Staff 1

acknowledged that not all residents current service plans had been added into

the service plan binders and had not been readily available to all staff.

CS observed the service plan binders in the medication room which had all

out-of-date service plans.

It was confirmed the facility failed to have service plans readily available to

staff.

On 08/20/24, the findings were reviewed with and acknowledged by Staff 1

and Staff 2 (Assistant ED).

Verbal plan of correction: ED will print all the current service plans. Speak with

RN on any service plans that may need to be completed and will have the

binders that are accessible up to date and signed by staff by the end of the

month.

Based on observation and interview conducted during a site visit on 08/20/24,

it was determined the facility did not have a system for tracking controlled

substances and for disposal of all unused, outdated, or discontinued

medications for 1 of 1 sampled resident (#6). Findings including, but are not

limited to:

On 08/20/24, Staff 1 (ED) indicated s/he had concerns around Resident 6's

Morphine, which was under investigation. It appeared the bottle leaked or had

been missing around 4 ml of medication. Staff 3 (MT) confirmed medication

had leaked or went missing and additional non-narcotic medication had been

sitting on the med room floor waiting to be disposed of.

CS's and Staff 3 (MT) observed a bottle of medication in a sealed bag which

appeared to have leaked around the bottle cap.

Review of disposal and destruction policy revealed:

 Both staff members must witness the destruction of medication

 Disposes of the medication in a medical waste receptacle

Review of tracking of controlled substance policy revealed:

 Both staff members review controlled substances at shift changes and

track any discrepancy to manager on duty.

Review of narcotic log for Resident 4's Morphine 20 MA/ML revealed a post-it

note which stated, "Staff 9 (RN) to look into more" dated 08/18/24.

Only one staff signature appeared on narcotic log from 08/18/24.

The findings were reviewed with and acknowledged by Staff 1 on 08/20/24.

It was determined the facility did not have a system for tracking controlled

substances and for disposal of all unused, outdated, or discontinued

medications.

Verbal plan of correction: Staff in internal investigation for Morphine on

suspension pending outcome of investigation. MT's and ED will dispose of

medications on floor of med room. This will be completed by 09/01/24.

Based on interview and record review, during a site visit conducted on

08/20/24, it was confirmed the facility failed to carry out medication and

treatment orders as prescribed for 2 of 6 sampled resident (#'s 2 and 3).

Findings include, but are not limited to:

During an interview, Staff 1 (ED) indicated there had been an agency staff

member who had neglected to provide required services to Resident 2 and

Resident 3, including not assisting with the removal of compression stockings

and applying cream.

A review of Resident 2's progress notes from 08/01/24 through 08/16/24

indicated the following;

 08/03/24, [Resident placed on alert charting for skin condition: lower legs

appearance, redness, warm at touch, weeping and small open areas

below knee.]

 08/04/24, [Resident has skin damage due to compression stockings

being worn longer than anticipated. It appears resident is not having

his/her stockings removed at bedtime.] and [med tech noticed

compression stockings had not been changed again since the day shift

yesterday.]

A review of Resident 2's MARs from 08/01/24 through 08/20/24 indicated

wound care to both legs, put on every morning and take off in the evening. On

08/11/24 and 08/13/24 in the mornings staff did not document completing the

task.

A review of Resident 3's MARs from 08/01/24 through 08/20/24 indicated the

resident missed the following medications;

 Atorvastatin 20MG for high cholesterol, one tablet by mouth every

evening. Resident missed doses on 08/16/24 and 08/17/24.

 Boudreauxs cream for dermatitis. Resident missed doses on 08/16/24

and 08/17/24.

 Famotidine 20MG for acid indigestion by mouth twice daily. Resident

missed both doses on 08/16/24 and 08/18/24, resident missed one dose

on 08/17/24.

On 08/20/24, the findings were reviewed with and acknowledged by Staff 1

and Staff 2.

Verbal plan of correction: The ED will pull the medications exception report

daily and follow-up. ED has "do not returned" the agency staff who was

responsible for ensuring resident services.