Print Inspection: X2D0

Based on interview and record review, conducted during a site visit on 06/05/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

During separate interviews on 06/05/24, Staff 1 (ED) stated the facility had switched medication management systems on 03/12/24. Staff 2 (MT) stated there had been issues when the system transfer had occurred. Some of the information from the old system had not transferred to the new system and the staff had to figure out what had not transferred over and resulted in missed medications.

A review of physician orders dated 03/12/24 through 04/03/24, and Resident 1's MARs dated 03/01/24 through 03/31/24, indicated the following medications that had not been administered:

·Oxycodone 5MG for pain three times a day at 8:00 AM, 2:00 PM and 8:00 PM. The facility was to start administering on 03/12/24 at 8:00 AM. Three doses were missed on 03/12/24.

·Trazodone 50MG for sleep. One dose was missed on 03/12/24.

·Latanoprost one drop in both eyes every night for glaucoma. One dose was missed dose on 03/12/24.

·"Acquire Oxygen saturations every shift and as needed for complaint of shortness of breath, per resident request or nurse instruction...notify PCP with O2 saturation below 88% three times a day..." On 03/20/24, these treatment was not acquired.

·Hydroxyzine 50MG three times daily morning, afternoon, and before bedtime for anxiety. Two doses were missed before bedtime on 03/12/24 and 03/19/24.

·Methocarbamol 500MG three times daily morning, afternoon, and before bedtime for muscle spasms. Two doses were missed before bedtime on 03/12/24 and 03/19/24.

·Oxycodone 5MG for pain three times a day at 8:00 AM, 2:00 PM and 8:00 PM. The facility was to start administering on 03/18/24 at 8:00 AM. Missed seven doses from 03/18/24 through 03/20/24.

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

On 06/05/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: In March the facility went through a mediation system change resulting in information to have not fully transferred over to the new system. The facility will continue to follow doctor's orders.

Based on interview and record review, conducted during a site visit on 06/05/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but not limited to:

Resident 2 no longer resided in the facility.

On 04/01/24, Witness 1 indicated Resident 2 needed his/her PRN morphine, then Resident 2 pressed his/her pendant at 12:30 pm and staff did not respond until 1:20 pm.

In an interview on 06/05/24, Staff 1 (Executive Director) indicated during the time of the complaint the facility was using a lot of agency staff and the facility had been very short staffed that many call lights had not been answered timely. There had been resident's toileting needs that had been missed as a result, and at least one resident who had an accident due to staff not responding to his/her call light timely.  

A review of Resident 2's call light history, dated 01/15/24 through 04/01/24, indicated 38 of 163 responses had exceeded 15 minutes. Of those 38 responses, 23 of them had exceeded 20 minutes. The longest wait time being 3 hours and 30 minutes wait time.

It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 06/05/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: Staff 1 stated that this occurrence happened in April before s/he had become the ED and the call lights have improved since then. Staff 1 will continue to audit call light response times.