There were 23 initial and recertification surveys available for review with 9 of the 23 resulting in insufficiencies averaging 5.6 and 3 receiving fines. Additionally, there were 14 complaint and incident surveys available for review with 11 resulting in an average of 3.1 insufficiencies cited and only 1 resulting in a fine.
The fines that were issued included:
- A $5,000 fine under 67.3(2) when staff failed to complete safety checks on a tenant that had a fall resulting in a hip fracture. During interviews, the staff reported that the computers didn’t always work due to connectivity issues.
- An $8,000 fine under 67.3(2) when a tenant’s MARs and TARs lacked documentation of treatment to several areas. In March, the tenant was hospitalized for sepsis, secondary to cellulitis, and there was multiple skin concerns identified during hospitalization that weren’t noted on a wound clinic visit shortly before the hospitalization. The tenant was hospitalized again in April due to a UTI and low blood glucose levels. During record review, the program did not monitor the blood glucose levels as ordered. A different tenant had a battery replacement in a deep brain stimulator with discharge instructions on surgical wound care including removing the dressing to the surgical site. Upon follow-up, the initial dressing was still intact. The same resident was later started an antibiotic due to wound infection on their legs when the documentation indicated they self-administered their treatments. Additional tasks weren’t completed that were outlined in the service plan including housekeeping, laundry, and showers. Other tenants had concerns with response to their pendants which averaged anywhere from 21 minutes to 105 minutes. Other concerns were identified during the survey including a failure to administer pain medication as the staff felt the tenant was pill-seeking, the dementia unit wasn’t provided with adequate amounts of food and temperatures were not within acceptable range when tested.
- A $2,500 fine was issued for 69.27(2) when the program’s failure to complete nurse reviews every 90 days on a tenant with chronic leg wounds that required assistance with wound care.
- A $2,500 fine was issued for 69.32(2) when two tenants eloped from the program when a staff member left an alarmed gate propped open while they took out the garbage.
The most frequently cited insufficiencies include:
- 69.26 related to service plans with examples of non-compliance including:
- Service plans lacked signatures of those participating in developing the service plan.
- The service plan wasn’t updated within 30 days of occupancy.
- The service plan didn’t include planned and spontaneous activities for those with dementia.
- Service plans lacked all necessary information including incontinence, behaviors, aggression, hospice, toileting assistance needs, changing to crushed medications, refusal to eat, falls, hospitalizations, changes to wound care needs, pain, ADL assistance, increased substance use, and therapy services.
- The service plans lacked documentation of the tenant’s preferred nursing home.
- 67.3 related to tenant rights with examples of non-compliance including:
- Tramadol wasn’t administered for 13 days due to the pharmacy discontinuing the medication.
- The tenant received a discharge notice for unpaid rent. However, when asked the program was unable to explain to the tenant why they had past due amounts.
- During observations a tenant was placed in an electric lift chair, reclined all the way back, and the chair was then unplugged as staff didn’t want them to get up and fall. Additionally, staff took the tenant’s pendant away from them as they felt that they used it too frequently.
- There was video evidence of staff failing to provide care for a long period of time along with the tenant’s worsening condition including dehydration and lack of wound care. Additionally, staff failed to remove a medication patch before applying a new one and there were multiple patches on the tenant’s back.
- Staff failed to treat the tenants with respect and dignity when they told the tenant they were tired of their behavior and ready to get their tasks done with.
- The program failed to follow proper involuntary discharge procedures for bed bugs.
- A staff member from another provider went to the assisted living to pick up a tenant who was moving to their building. The staff failed to communicate the tenant’s needs as they were unable to sit up in a wheelchair for safe transport and during the transfer the driver had to pull over multiple times to prevent the tenant from falling.
- Staff failed to properly assist tenants at mealtimes, didn’t administer medications as ordered, complete safety checks and the tenant’s records lacked documentation of safety checks.
- 67.9 related to staffing with examples of non-compliance including:
- The tenant required assistance of 2 staff for transfers, but the memory care was only staffed with 1 person.
- Unusual tenant concerns weren’t reported to the program nurse on the communication forms.
- Pendant response times were very delayed and families expressed concerns about the staffing levels at the program.
- The program nurse didn’t provide supervision to ensure staff were competent in providing care and services including when staff failed to remove medication patches prior to placing a new patch and staff didn’t respond to tenant’s needs timely.
- Staff lacked competencies with medication transcription.
- Staff weren’t passing medications in accordance with standards of practice.
- 69.25 related to tenant documents with examples of non-compliance including:
- Nurses’ notes weren’t documented by exception including a change in condition, worsening of wounds, bruising, medication errors, ER visits, and starting new medications.
- Tasks weren’t documented when completed.
- Incident reports weren’t completed.
- Staff documented that nebulizers were administered but the tenant didn’t have a nebulizer machine.