Print Inspection: QEEG

Based on interview and record review, conducted during a site visit on 04/30/24, 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 March 2024 MAR and progress notes, signed 90 day orders, and suspected abuse or unexplained injury reporting form dated 03/08/24, indicated the following:

·90 day orders show Quetiapine 25 MG Tab (Serequel) to be given 0.5 Tablet (12.5 MG) by mouth every morning. Ok to crush and mix with food for mood,

·90 day orders show Quetiapine 25 MG Tab (Serequel) to be given 1 Tablet by mouth every evening. Ok to crush and mix with food for mood,

·Suspected abuse or unexplained injury reporting form dated 03/08/24 indicated  "On 3/8/24 it was discovered that resident had been getting a ½ tab of [his/her] Seroquel rather than a whole tab as ordered.  No adverse reactions occurred."

In an interview, Staff 2 (MC ED) stated s/he was not aware of the details of the incident.

The findings were reviewed with and acknowledged by Staff 2 on 04/30/24.

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

Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.

Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

A review of Resident 3's March 2024 MAR and progress notes, physician orders, and Event Report dated 03/22/24, indicated the following:

·Orders show Secura Protective 10% cream (zinc oxide) Topically apply to affected areas when resident is changed to help improve healing over time. Note this is scheduled to correspond to changes, as a preventative to excoriation/urine burn

·Event report dated 03/22/24 indicated  "Resident did not receive their Secura cream-not on hand"

·MAR indicated Secura Protective 10% cream was not administered at 4:06pm or at 9:34pm due to none on hand on 03/22/24

In an interview, Staff 2 (MC ED) stated s/he was made aware of the incidents, and they were reported to APS.

The findings were reviewed with and acknowledged by Staff 2 on 04/30/24.

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

Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.

Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

A review of Resident 2's April 2024 MAR and progress notes, and Event Report dated 04/02/24, indicated the following:

·MAR shows Lisinopril 40 MG Tab (Zestril) 1 Tablet by mouth every day hold if systolic is less than 110,

·MAR shows Quetiapine 25 MG Tab (Seroquel) 1 Tablet by mouth 2 times daily

·Event report dated 04/02/24 indicated Resident 2  " missed PM (4/1/24) dose of medications Lisinopril 40 MG tab and Quetiapine 25 MG tab "

In an interview, Staff 2 (MC ED) stated s/he was made aware of the incidents, and they were reported to APS.

The findings were reviewed with and acknowledged by Staff 2 on 04/30/24.

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

Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.

Based on interview and record review, conducted during a site visit on 04/30/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 3 of 3 sampled residents (#'s 2, 3, and 4). Findings include, but are not limited to:

A review of Resident 2's March 2024 MAR and progress notes, physician orders, and suspected abuse or unexplained injury reporting form dated 03/21/24, indicated the following:

·Orders show Latanoprost 0.005% drops (Xalatan) to instill 1 drop in both eyes every evening for Glaucoma,

·Suspected abuse or unexplained injury reporting form dated 03/21/24 indicated on 3/11/24  "Resident did not get eye drops, Latanoprost, due to none on hand."

A review of Resident 3's March 2024 MAR and progress notes, physician orders, and suspected abuse or unexplained injury reporting form dated 03/21/24, indicated the following:

·Orders show Secura Protective 10% cream (zinc oxide) Topically apply to affected areas when resident is changed to help improve healing over time. Note this is scheduled to correspond to changes, as a preventative to excoriation/urine burn

·Suspected abuse or unexplained injury reporting form dated 03/21/24 indicated on 3/12/24  "Secura was held due to no redness"

A review of Resident 4's March 2024 MAR and progress notes, physician orders, and Event Report dated 03/25/24, indicated the following:

·MAR shows Trazodone 50 MG Tab (Desyrel) 2 Tablets (100 MG) by mouth every night at bedtime Ok to crush per MD for sleep,

·Event Report dated 03/25/24 indicated medication was not given on 3/25/24  "Residents Trazadone has not arrived from pharmacy. Rx refill was sent on 03/24/24"

In an interview, Staff 2 (MC ED) stated s/he was made aware of the incidents, and they were reported to APS.

The findings were reviewed with and acknowledged by Staff 2 on 04/30/24.

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

Verbal plan of correction: Facility had a 4-hour MT training for all staff administering medications, starting at the end of March 2024. Any new med techs are now starting out with that class, going over the medication training navigator. ED and Nurse have been sitting down with each med tech one on one for additional training. They are doing daily clinical where they are looking at MAR and orders to audit for any missed meds or meds that were not passed. If a med tech is unable to find a medication, they are to have another med tech look for it, and then contacting the on-call supervisor if it cannot be located. Additional education has been provided to staff regarding re-ordering medications when there is a 10-day supply left.