Print Inspection: DVB0

Based on interview and record review, conducted during a site visit on 10/10/24, it was determined the facility failed to determine and document what action or intervention is needed if a resident experiences a short-term change of condition for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

A review of the facility's policy and procedures for change of condition, indicated the following:

·The licensed nurse will determine the type of intervention and follow-up that is indicated, including appropriate notification of the Resident's family or responsible party and physician. Notifications to the Residents'  responsible party and primary provider will be noted in the Resident health Record.

·The resident will be place on alert charting.

A review of Resident 1's February-March 2024 progress notes indicated the following:

·02/21/24 at 3:55 AM  "resident is on alert for skin issue. Resident was asleep this shift, will continue to monitor "

·02/21/24 at 1:06 PM  "Resident received new orders for script for shingles"

·02/22/24 at 6:14 PM Nursing note  "Resident is on alert for new shingles diagnosis. MT came to me and notified me of redness and blisters below right breast that followed the nerve line. This was report to NP [in house provider] on 02/21/24 and resident was diagnosed with Shingles."   "Add resident to alert charting and ISP to monitor shingles".

In an interview on 10/10/24, Staff 1 (Executive Director) and Staff 2 (Regional Nurse) stated the following:

·Staff 1 was unaware of the situation as s/he started working at the facility on 08/20/24.

·Short term change of conditions was to be reported to the nurse, and then the doctor and family should have been notified.

·They would use a TSP or ISP for initial notification to staff and put it in the binder.

·The med tech should document every shift when on alert.

Compliance specialist requested Interim Service Plan from facility, however, they were unable to provide them. There was no documentation regarding what actions or interventions were needed or what staff was to monitor and report.

Witness 1 reported on 03/07/24, Resident 1 was at the doctor's office with Shingles around his/her torso on 02/22/24 and there had been no communication to him/her from the facility prior.

Findings were reviewed with and acknowledged by Staff 1 on 10/10/24.

It was determined the facility failed to determine and document what action or intervention is needed if a resident experiences a short-term change of condition.

Based on interview and record review, conducted during a site visit on 10/10/24, it was determined the facility failed to have a safe medication and treatment system in place for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

A review of Resident 1's August 2024 MAR and progress notes, and physician orders indicated the following:

·Docusate Sodium 100 MG softgel to be given 1 capsule by mouth twice daily for constipation was not administered on 08/12/24 at 8:00 PM or on 08/13/24 at 8:00 AM due to  "Med not on hand".

·Hydroxychloroquine 200 MG tab to be given 1 tablet by mouth twice daily for inflammatory polyarthropathy. Resident missed 4 doses between 08/12/24-08/14/24 due to  "Med not on hand".

·Memantine HCL 5 MG tablet to be given 1 tablet by mouth once a day for Alzheimer's disease was not administered on 08/13/24 at 7:00 AM due to medication not available.

A review of Resident 2 and Resident 3's August 2024 MAR and progress notes did not indicate any discrepancies.

In an interview, Staff 1 (Executive Director) stated  "missed meds, historically, were a problem and are decreasing" . S/He stated the process was getting better.

The findings were reviewed with and acknowledged by Staff 1 on 10/10/24.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Plan of correction: Daily clinicals are in place to audit alert charting, missed medications, medication errors, and change of condition. Weekly re-education by the nurse and management for MTs regarding medication administration, orders, and re-fills. Facility is also sending out quarterly renewal letters to physicians.

Based on interview and record review, conducted during a site visit on 10/10/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

A review of Resident 1's August 2024 MAR and progress notes, and physician orders indicated the following:

·Docusate Sodium 100 MG softgel to be given 1 capsule by mouth twice daily for constipation was not administered on 08/12/24 at 8:00 PM or on 08/13/24 at 8:00 AM due to  "Med not on hand".

·Hydroxychloroquine 200 MG tab to be given 1 tablet by mouth twice daily for inflammatory polyarthropathy. Resident missed 4 doses between 08/12/24-08/14/24 due to  "Med not on hand".

·Memantine HCL 5 MG tablet to be given 1 tablet by mouth once a day for Alzheimer's disease was not administered on 08/13/24 at 7:00 AM due to medication not available.

In an interview, Staff 1 (Executive Director) stated  "missed meds, historically, were a problem and are decreasing" . S/He stated the process was getting better.

The findings were reviewed with and acknowledged by Staff 1 on 10/10/24.

It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Plan of correction: Daily clinicals are in place to audit alert charting, missed medications, medication errors, and change of condition. Weekly re-education by the nurse and management for MTs regarding medication administration, orders, and re-fills. Facility is also sending out quarterly renewal letters to physicians.