(1) Assistance with walking and moving, dressing, grooming, toileting, oral hygiene, hair care, dressing, eating, and nail care;

Transcription

1 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING 000 INITIAL 000 Type of inspection: Complaint investigations #OH , #OH , & #OH The complaints are substantiated. Date of on-site exit: 06/13/08 Licensed capacity: 05 Current facility census: 01 Community Mental Health: 01 License expiration: 03/14/09 Due to the extreme health and safety violations found during the investigation of these complaints, this ACF's file is referred to the Bureau of Regulatory Compliance. O.A.C (B) PROVISION OF PERS CARE SVC An ACF shall provide personal care services to residents who require those services and may provide personal care services to other residents upon request. If a resident requires certain personal care services that the facility does not offer, the facility either shall arrange for the services to be provided or shall transfer the resident to an appropriate setting in accordance with section Of the Revised Code and rule of the Administrative Code. Personal care services include, but are not limited to, the following: (1) Assistance with walking and moving, dressing, grooming, toileting, oral hygiene, hair care, dressing, eating, and nail care; (2) Assistance with self-administration of medication, in accordance with section of the Revised Code and paragraph (C) of this rule; LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 9

2 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 1 (3) Preparation of special diets, other than complex therapeutic diets, for residents who require them, pursuant to the instructions of a physician or a licensed dietitian and in accordance with paragraph (B) of rule of the Administrative Code; and (4) Nothing in this paragraph shall be construed to permit personal care services to be imposed upon a resident who is capable of performing the activity in question without assistance. Based on interviews, at least two (2) residents were not afforded assistance to self-administer their prescription medications. Findings include: 1. Resident #1's record revealed the resident was ordered Remeron, Cogentin, Clonidine, Haldol, Depakote, Norvasc, Trazodone, and Hydralazine. The facility owner stated she needed to "hold" some of the medications when the resident appeared too sedated in the facility owner's assessment. She confirmed she had not documented when she took this action and that she had not reported her actions to the resident's physician or sponsor such as case manager. She denied knowing this action would be in violation of licensure rules. 2. Resident #1 was confirmed by employee #2 to not have been approached to take his morning medications on 06/09/08. Resident #1 was found dead at around 1 PM this same day. (The facility owner denied during interview on 06/13/08 that there were any prescription medications for Resident #1 left in the facility as the coroner had taken them on 06/09/08.) If continuation sheet 2 of 9

3 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 2 3. Resident #2 was also confirmed by employee #2 to not have been approached to take his prescription medications on the morning of 06/09/08. His medications included Cogentin, Citalopram, Glyburide, Oxybutynin, Haldol, and Lipitor. Resident #2 was also found non-responsive around 1 PM this same day. 4. Employee #2 stated he had chosen not to awaken residents #1 and #2 on 06/09/08 in spite of physician orders that required morning medications be locked by the facility and taken by residents under the supervision of the facility. This violation substantiates the O.A.C (A) CHANGES RESENT HEALTH In the event of a significant change in physical health or behavioral status, the facility shall do all of the following: (1) Take immediate and proper steps to see that the resident receives necessary intervention including, if needed, medical attention or transfer to an appropriate health care facility; (2) Make a notation of the significant change in physical health or behavioral status and any intervention taken in the resident's record; (3) Provide pertinent resident information to the person providing the intervention as soon as possible; and (4) Immediately notify the resident's case manager and sponsor of the significant change in physical health or behavioral status and actions If continuation sheet 3 of 9

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5 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING Continued From page As used in this paragraph, "incident" means any accident or episode involving a resident, staff member, or other individual in an ACF which presents a risk to the health, safety, or well-being of a resident of the facility. In the event of an incident, the facility shall do all of the following: (1) Take immediate and proper steps to see that the resident or residents involved receive necessary intervention including, if needed, medical attention or transfer to an appropriate health care facility; (2) Immediately, but no later than twenty-four hours after the incident, notify the resident's case manager(s) and sponsor(s) of the incident and subsequent actions taken; (3) Investigate the incident and document the incident and the investigation. The documentation shall contain the names of individuals involved; the time, place, and date of the occurrence; a description of the incident; the probable cause; and the care provided or measures taken; and (4) Notify the state department of health adult care facility program of the incident and results of the investigation within twenty-four hours if the incident resulted in actual harm to a resident or staff member or had significant impact on the facility's environmental or physical plant systems. Based on interview with the facility owner on 06/13/08, the facility fails to demonstrate immediate and proper steps were taken to ensure resident safety during an excessive period of heat. Findings include: If continuation sheet 5 of 9

6 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING Continued From page 1. As of 06/13/08, the facility owner and her employee had failed to document in any manner the finding of sudden and critical changes in health for residents #1 and #2 on 06/09/ During interview on 06/13/08, the owner (Employee #1) failed to demonstrate any investigation into why Employee #2 and she (Employee #1), who were both reportedly present in the 12 hours prior to finding the residents had not taken responsibility to ensure the residents took their morning medications, drank fluids knowing of the excessive heat, provided breakfast and lunch, and why no one even visually checked on the safety of residents #1 and #2 until 1:00 pm in the O.A.C (G) CLEAN HEALTHY Each facility shall assure a safe, clean, healthy environment by doing at least the following: (1) Eliminating any existing insects and rodents and taking effective measures to prevent the presence of insects and rodents in and around the facility; (2) Avoiding temperature extremes within the facility which may be a health hazard to the residents; (3) Providing durable garbage and refuse receptacles to accommodate wastes. Outdoor garbage and refuse receptacles shall be kept covered with tight-fitting lids at all times; (4) Promptly and thoroughly cleaning toilets, bathrooms, and other obvious sources of odors; (5) Establishing and implementing housekeeping and maintenance procedures to assure a clean, safe, sanitary environment and a home-like If continuation sheet 6 of 9

7 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING Continued From page appearance to the facility; and (6) Protecting the drinking water supply against contaminating sources. Based on interviews, the facility bedroom temperature was excessively hot on 06/09/08 and the facility failed to implement adequate and timely safeguards to prevent resident harm. Findings include: 1. When the emergency medical squad and the cororner came to the facility on 06/09/08 two residents were unresponsive in an upstairs bedroom that registered 90 degrees Fahrenheit. 2. Subsequent interview on 06/13/08 with the facility owner revealed she "turned on" a fan in the bedroom when she found the two residents in the room, one of whom she determined required CPR while she awaited 911 response. 3. Interview with the facility owner and employee #2 revealed the residents in this bedroom had been allowed to "sleep" through breakfast and lunch and the bedroom had not been checked for excessive heat in spite of a heat wave for several days in the 90's with high humidity. This violation substantiates the O.A.C (B)(1) SAFE HEALTH CLEAN The facility must assure the right of a resident to a safe, healthy, clean, and decent living environment. If continuation sheet 7 of 9

8 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING Continued From page Based on the findings throughout this report, the facility has failed to provide a safe environment for residents. This violation substantiates the O.A.C (B)(15) FREE FR ABUSE, NEG, The facility must assure the right of the resident to be free from abuse, neglect, or exploitation. Based on record reviews and interviews, the facility neglected to provide a reasonable level of care to at least two (2) facility residents which resulted in harm to both residents. Findings include: 1. See tag 1701 in this report regarding facility staff not providing medications as physician directed. 2. See tag 1901 in this report regarding the failure of the facility to demonstrate timely supervision of residents. 3. See tag 2221 in this report regarding the failure of the faciliy to provide a means to cool residents at high risk for adverse reactions to heat due to psychotrophic medications taken. 4. Resident #1 died on 06/09/08 and laid in the facility unnoticed for hours until 1 PM in spite of staff reportedly being present in the home. 5. Resident #2 was also found to be If continuation sheet 8 of 9

9 NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: B. WING (X3) SURVEY D (X4) REGULATORY OR LSC ENTIFYING Continued From page hyperthermic on 06/09/08 and to be expiriencing massive bodily shutdown. He was in the same hot bedroom with resident #1 without even a fan on. He died in the hospital on 06/16/08. If continuation sheet 9 of 9