Print Inspection: I96F

Based on observation and interview, during a site visit conducted on 04/10/24, it was confirmed the facility failed to have medical and other records kept confidential. Findings include, but are not limited to:

On 04/10/24, CS observed a medication cart unattended with the computer unlocked and residents MARs open as well as access to other resident records accessible.  

During an interview on 04/10/24, Staff 1 (ED) indicated computers on the medication carts should be locked and closed before an MT walked away from the cart.

It was confirmed the facility failed to have medical and other records kept confidential.

On 04/10/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The ED will have a meeting with all staff to remind them that the computers are to be locked before walking away from the computer.

Based on observation, interview, and record review, during a site visit conducted on 04/10/24, it was confirmed the facility failed to ensure implementation of services for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Separate interviews with Staff 1 (ED) and Staff 2 (RCC) indicated the facility had run out of options for interventions for Resident 1. Staff 1 indicated the facility had attempted to move Resident 1 to a behavioral facility, however, had not attempted to contact a behavioral specialist.

Resident 1's interventions report, from 12/15/23 through 04/07/24, listed the following interventions which were put in place after altercations with other residents:

·12/15/23- Staff to escort resident to and during meals to minimize him/her wanting food from other plates.

·12/19/23- Staff to always walk with resident when seen out in the community to help redirect.

·01/21/24- Ensure a sign be placed on resident's walker which stated, "do not touch."

·02/04/24- Resident to be escorted by staff in all areas of the community, once observed outside his/her apartment.

·02/10/24- Staff to monitor and redirect. Staff to engage by offering individualized activities in-between meal times.

·02/13/24,03/09/24, and 03/11/24- Staff to monitor.

·04/07/24- Play jazz music for resident.

Progress notes from 01/31/24 through 02/19/24 indicated for each intervention the following chart note, "Record observations every shift for three days to monitor the effectiveness of the following intervention." Chart notes indicated the staff would not consistently chart for three days nor state whether the intervention had been effective. After the third day the following chart note would be made, "Staff have monitored resident every shift with no further incidents reported, closing out the alert."  

A review of Resident 1's service plan dated 01/02/24 indicated the following;

·If resident becomes agitated redirect him/her away from trigger residents.

·If another resident bothers him/her try talking about horses, books, and woodworking.

·Encourage resident to seek out a staff member.

·Encourage to use words not hands, redirect the other resident.

On 04/10/24, CS did not observe Resident 1 engage in any altercations or display any negative behaviors. Staff were not escorting resident throughout the building, however had an eye on him/her and deescalated before an altercation could occur. There was no sign observed on Resident 1's walker.

It was confirmed the facility failed to ensure implementation of services.

On 04/10/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The ED will get in contact with a behavioral specialist with in five days and have more follow through with charting interventions set in place.