Print Inspection: OJPO

Based on interview and record review, conducted during a site visit on 07/19/23, it was confirmed the facility failed to complete a service plan before a resident move-in, with updates and changes as appropriate within the first 30-days, and following quarterly evaluations for 3 of 3 sampled residents' (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:

In an interview on 7/19/23 Staff 1 (Executive Director) stated s/he was aware that the facility continues to have issues with creating service plans before residents move in as well as keeping them updated as required. S/he stated service plans were not available to staff. S/he reported that the facility has contracted with a nursing consulting team to assist with bringing the facility up-to-date on all service plans.

On 07/19/23, a review of resident's service plans indicated the following:  

Resident 1 moved in on 06/01/23. There was no evidence to indicate any service plan was developed before move in or after.

Resident 2 moved in on 03/24/23. There was no evidence to indicate the facility updated the his/her service plan within 30 days of move-in or quarterly.

Resident 3 moved in on 01/30/22. There was no evidence to indicate the facility updated the his/her service plan following quarterly evaluation since 10/22/22.

In an electronic correspondence, dated 07/20/2023, Staff 1 stated they completed a Service Plan Correction Audit and identfiied 50 out of 73 residents' service plans had not been updated quarterly.

­­­­­­

It was confirmed the facility failed to complete a service plan before a resident move-in, with updates and changes as appropriate within the first 30-days and following quarterly evaluations.

On 07/19/23, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction:

Within 30 days, Staff 1 will work with the nurse consulting team to ensure all service plans are up-to-date and new residents' service plans are completed prior to their date of move-in.

Based on observation, interview, and record review, conducted during a site visit on 07/19/23, it was confirmed the facility failed to implement a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility for 2 of 2 sampled residents' (#s 1 and 2) whose medications were reviewed.  Findings include, but are not limited to:

In an interview on 07/19/23, Staff 1 (Executive Director) stated the facility has issues with their current narcotics system. S/he reported the facility has not destroyed expired or deceased resident medications since 11/02/22. The facility's current policy and procedure for the disposal of medications is vague and does not state a timeframe or process for destroying medications. S/he has been working to update the policy and procedure. S/he stated this process is further compounded by the facility not having a RN for an extended period of time. S/he stated they are now working with a nursing consulting team and will have a new RN hired the beginning of August.

In a separate interview on 07/19/23, Staff 4 (Med Tech) explained how the facility does their narcotic count, which is completed after each shift. S/he stated there is a process for destroying expired or deceased resident medication, however, it has not been getting done. When they do the narcotic count, they have a binder with each resident listed stating how much medication they have left. The MT verify that number is correct and sign off on that sheet. With the expired or deceased resident medication, Staff 4 stated the MT put that medication in the back of the cart, so they are still able to count it but know not to use it. Staff 4 stated this process is working for them, the concern is the RN should be destroying the medication and that is not happening. S/he stated staff have expressed to the corporate RN and the nursing consulting team that the medications needed to be destroyed but it is not getting done.

A review of the Medication Disposition Record Log indicated no medication had been destroyed between 11/02/22 and 06/29/23. The facility's Narcotic Logbook was reviewed on each medication cart.The facility's Controlled Medicaion Disposal Policy stated:  "C: Schedule II medications remaining in the facility after a resident has been discharged, or the order discontinued, are disposed of as directed by state laws, regulations, and/or the DEA. D: Schedule III, IV, and V controlled substances are disposed of at the facility by two licensed personnel, as directed by state law."

On 07/19/23, CS observed expired and deceased residents' medications stored in the back of two medication carts. CS identified three medication cards belonging to Resident 4 that expired on 04/27/23 and one medication card belonging to Resident 5 that expired on 03/03/23.

It was confirmed the facility failed to implement a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility.

On 07/19/23, the findings were reviewed with and acknowledged by Staff.

Verbal plan of correction:

Staff 1 will revise and update the facility's policy on disposal of medications to include a RN needs to be included weekly.