On letterhead

Transcription

On letterhead

STATE OF M ICHIGAN
DEPARTMENT OF HUMAN SERVICES
OFFICE OF CHILDREN AND ADULT LICENSING
JENNIFER M. GRANHOLM
MARIANNE UDOW
GOVERNOR
DIRECTOR
April 26, 2007
Jamie Bragg-Lovejoy
Alternative Community Living, Inc.
70 Lafayette
Pontiac, MI 48342
RE: License #: AM730262697
Investigation #: 2007A0867013
Agnes Rambo
Dear Ms. Bragg-Lovejoy:
Attached is the Special Investigation Report for the above referenced facility. Due to
the violations identified in the report, a written corrective action plan is required. The
corrective action plan is due 15 days from the date of this letter and must include the
following:
•
How compliance with each rule will be achieved.
•
Who is directly responsible for implementing the corrective action for each
violation.
•
Specific time frames for each violation as to when the correction will be
completed or implemented.
•
How continuing compliance will be maintained once compliance is
achieved.
•
The signature of the licensee or licensee designee and a date.
If you desire technical assistance in addressing these issues, please feel free to contact
me. In any event, the corrective action plan is due within 15 days. Failure to submit an
acceptable corrective action plan will result in disciplinary action.
P.O. BOX 30650 • LANSING, MICHIGAN 48909-8150
www.michigan.gov • (517) 335-6124
Please review the enclosed documentation for accuracy and feel free to contact me with
any questions. In the event that I am not available and you need to speak to someone
immediately, please feel free to contact the local office at (989) 835-7241.
Sincerely,
Diane L Stier, Licensing Consultant
Office of Children and Adult Licensing
1475 S Bamber Road
Mt. Pleasant, MI 48858-8010
(989) 772-8479
Enclosure
P.O. BOX 30650 • LANSING, MICHIGAN 48909-8150
www.michigan.gov • (517) 335-6124
MICHIGAN DEPARTMENT OF HUMAN SERVICES
OFFICE OF CHILDREN AND ADULT LICENSING
SPECIAL INVESTIGATION REPORT
I. IDENTIFYING INFORMATION
License #:
AM730262697
Investigation #:
2007A0867013
Complaint Receipt Date:
02/22/2007
Investigation Initiation Date:
02/22/2007
Report Due Date:
04/23/2007
Licensee Name:
Alternative Community Living, Inc.
Licensee Address:
70 Lafayette
Pontiac, MI 48342
Licensee Telephone #:
(248) 338-7458
Administrator:
Mary Banaszak
Licensee Designee:
Jamie Bragg-Lovejoy, Designee
Name of Facility:
Agnes Rambo
Facility Address:
4845 Shattuck
Saginaw, MI 48603
Facility Telephone #:
(989) 799-4129
Original Issuance Date:
06/01/2004
License Status:
REGULAR
Effective Date:
12/01/2006
Expiration Date:
11/30/2008
Capacity:
8
Program Type:
MENTALLY ILL
DEVELOPMENTALLY DISABLED
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II.
ALLEGATION(S)
•
•
•
•
•
•
•
•
III.
Residents do not always have access to their money. Resident funds records
are not kept current.
Staff are told by the home manager to fabricate outings and enter van mileage
anyway.
Documentation in resident books is not kept up to date and documents are
forged.
Residents are not receiving medications as prescribed.
A resident was forced to take medication that had been dropped on the floor.
Toilet paper is not always available.
There is evidence of mice and ants in the home.
The home manager is rude to residents and uses an unacceptable tone of voice.
METHODOLOGY
02/22/2007
Special Investigation Intake
2007A0867013
02/22/2007
Special Investigation Initiated - Telephone
ORR 1
02/22/2007
Contact - Face to Face
Interviews
02/22/2007
Inspection Completed On-site
02/26/2007
Staff interviews
02/27/2007
Resident interviews
02/27/2007
02/28/2007
Contact - Telephone call made
Licensee Designee
03/02/2007
Files
03/09/2007
Contact - Telephone call received
ORR 1
03/13/2007
Inspection of records
2
03/13/2007
RN 1
03/14/2007
Records
03/15/2007
Contact - Document Received
Preliminary CAP
03/19/2007
Contact – Telephone call received
ORR 1
03/20/2007
Licensee Designee
03/20/2007
ORR 1
03/20/2007
Contact – Document received
From ORR 1
03/22/2007
Review of records
04/02/2007
Review of records; interviews
04/18/2007
Contact – Telephone call made
Interview with Parent B
04/23/2007
Exit Conference
By phone with licensee designee
ALLEGATION:
•
Residents do not always have access to their money. Resident funds records
are not kept current.
INVESTIGATION:
On February 22, 2007, ORR 1 informed the consultant that she had received several
allegations about the facility, one of which was that residents did not have access to
their money unless the administrator or home manager was in the facility, since only
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these two persons had keys to the money box or safe. ORR 1 said she had also
received information that records of resident funds are not kept current.
On February 22, 2007, the consultant interviewed CMH 1, who reported that he had
recently gone to the facility and asked staff about how residents’ money is handled.
CMH 1 told the consultant that the staff seemed to know nothing about resident money.
CMH 1 said he was told by staff that there were 2 separate boxes containing resident
funds, only the smaller of which could staff access. This smaller box contained only
small amounts of money.
On February 22, 2007, the consultant received and reviewed a written statement from
CSM 1. CSM 1 reported that she had been at the facility on Saturday, February 17,
2007, and asked staff about resident funds. CSM 1 wrote that Staff 5 and Staff 2
showed her a locked box which is available to staff after the first shift (when
management is on duty) leaves and on weekends. CSM 1 reported that this box
contains very little money, but is all the staff have access to when management is not in
the facility. CSM 1 reported that she asked staff how there were supposed to take
residents out if the residents wanted to go out, and staff said that they couldn’t do
anything if there was no money left in the small lockbox. Staff indicated to CSM 1 that
the rest of the residents’ funds is kept in a large safe to which only Staff 1 and Staff 20
had access. Staff 5 told CSM 1 that Resident D wanted to take money to eat at the
bowling alley one day, but could not get something to eat because there was not
enough money left in the lockbox. CSM 1 wrote that she tried to check the resident
funds ledgers, but found that the balances couldn’t be verified because of not having
access to whatever money was in the safe. CSM 1 wrote that the ledgers had not been
balanced recently. CSM 1 reported that she found the following when comparing
money available in the lockbox to the Resident Funds Part II sheets for the residents for
whom she serves as case manager:
Resident
Funds in Lockbox
Balance on Resident Funds
Part II
Resident D
$2.00
$17.34 – 10/27/06
$0.00 – 12/1/06 (2nd sheet)
Resident E
$5.00
$94.48
Resident F
$0.00
$20.46
Resident H
$10.00
$39.82
The consultant reviewed the Corrective Action Plan signed by the Licensee Designee
on November 16, 2006, in response to the licensing renewal investigation conducted by
Consultant 2. Of note was the response to two violations of Rule 315(3). In particular,
the Licensee Designee agreed that: “Licensee will note on Resident Funds Part II all
financial transactions including payment for foster care and on a separate Part II any
cash transactions.”
On February 26, 2007, the consultant interviewed staff of the facility. Staff 6 reported
that there used to be money available in the lockbox, but that there hadn’t been any
lately. Staff 6 said that if the residents are going on an outing, then Staff 1 makes sure
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there is money in the box. Staff 6 said he didn’t know anything about bowling or
residents eating at the bowling alley.
On February 26, 2007, Staff 4 reported that since the middle of January or so, residents
have been able to get money sometimes. Staff 4 said, “People don’t have to write it
down unless they feel like it.” Staff 4 said that they all went out to eat one day, but that
the staff and residents all paid for their own meals. Staff 4 said that Staff 1 said that she
had the house money planned for other outings. Staff 4 said that no resident ate in the
home that day. Staff 4 said this happened around the 1st of February on a weekday.
Staff 4 said that they went to the Chinese Super Buffet, a place that Resident G likes.
Staff 4 reiterated that both staff and residents paid for their own meals and that “house”
money was not used.
On February 26, 2007, Staff 3 reported that they had taken all the residents to the
Chinese buffet and that the residents and staff all paid for their own meals, because
Staff 1 said she was saving the house money for something else. Staff 3 said that the
money is gone now and they never knew what Staff 1 was saving it for or what it got
used for.
On February 27, 2007, the consultant interviewed Witness 1, a former staff person, in
conjunction with ORR 1. Witness 1 said that when staff and residents went out to eat,
sometimes Staff 1 would take the (“house”) credit card, but other times Staff 1 would
take the residents’ money and have them pay for it. Witness 1 said that Staff 1 decided
who was going to pay. Witness 1 said that Staff 1 would use it as an activity or outing
and pay for it with the credit card sometimes. Witness 1 said that when everyone went
out to eat, it was usually for lunch and there wouldn’t have been any meal fixed in the
house.
Administrator Mary Banaszak told the consultant she understood that resident funds
were not to be used to pay for meals outside the home when no meal was provided in
the facility. Ms. Banaszak showed the consultant a March 2007 receipt showing that all
residents went out to eat and that the facility credit card was used to pay.
On February 27, 2007, the consultant interviewed Witness 1, a staff person until
February 2, 2007. Witness 1 said that when residents got their checks, staff would take
the residents to cash their checks, and then bring the money to Staff 1, who put it in the
safe. Witness 1 said that at that time, only Staff 1 had access to the safe. Witness 1
reported that Staff 1 told her and other staff not to put receipts in the lock box (when
purchasing items for residents), but to put the receipts in Staff 1’s office. Witness 1 said
that receipts would often end up missing, so that there really wasn’t an accurate
account of where resident money went once it was moved from the safe into the lock
box.
On March 13, 2007, the consultant received and reviewed a copy of a Progress Note
written by CSM 1 and dated March 6, 2007. CSM 1 reported that she had received a
phone call from Resident B’s father, Parent B, with concerns about the facility. CSM 1
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reported that Parent B told her that Staff 1 told him Resident B needed $50.00 for
spending money. Parent B brought it to the home and gave it to Staff 1, but Staff 1 did
not give Parent B a receipt, nor did Staff 1 record the money in any log book that he
could see. Parent B told CSM 1 that he wanted to know where the money was going.
On March 13, 2007, the consultant examined Resident B’s Resident Funds Part II form.
This form showed a balance of $50.28. A $50 deposit had been entered by Staff 1
dated March 2, 2007. The consultant examined Resident B’s money available in the
lockbox and in the safe, in conjunction with Administrator Mary Banaszak. $24.75 was
in Resident B’s bag in the safe. $20.27 was in an envelope marked with Resident B’s
name in the lockbox. The Resident Funds Part II form had a subtraction error; when the
$50.00 deposit was recorded, the resident’s previous balance had been $-0.28. This
deficit was added to rather than subtracted from the $50.00 deposit. The resident’s
actual fund balance should have been $49.72. The total of Resident B’s cash in the
facility was $45.02. Thus, $4.70 of Resident B’s money was missing and unaccounted
for.
On March 22, 2007, the consultant again examined Resident B’s Resident Funds Part II
form. The subtraction error noted on the previous inspection had not been corrected.
On March 13, 2007, the consultant conducted an onsite investigation and examined
resident funds. Administrator Mary Banaszak explained to the consultant that up to $20
of a resident’s cash is now kept in a small lockbox to which staff have access. The
remainder of a resident’s money is kept in a safe located on the floor of the office. The
consultant examined the Resident Funds Part II forms for all residents, and noted that
most withdrawals prior to February 2007 were marked as “Personal Funds” and were in
even dollar amounts. Ms. Banaszak told the consultant that these entries were
essentially recording that money was moved from the safe to the lockbox. The
consultant asked to see records for the disbursement of the cash that was kept in the
lockbox for each resident, and was told that there did not seem to be records for these
transactions. The consultant provided technical assistance regarding the proper way to
record transactions on the Resident Funds Part II forms. Ms. Banaszak indicated that
staff would be instructed to record all cash transactions directly on the Resident Funds
Part II forms in the future.
On March 13, 2007, Staff 8 told the consultant that each shift is supposed to count the
money in the lockbox and sign a paper that keeps track of this. Staff 8 wasn’t sure
where that paper was kept. Staff 8 also reported that the home formerly didn’t keep
cash for Resident C, because Resident C was able to handle her own money.
However, Resident C incurred a debt she needs to repay, and has given the home a
written document asking that they keep money as she gives them cash from her
spending money, until she has accumulated the amount needed to repay the debt.
Staff 8 said they were only keeping track of this money on the envelope it is kept in, in
the lockbox. The consultant informed Staff 8 and Administrator Mary Banaszak that
ALL resident funds must be documented using the Resident Funds Part II form. Ms.
Banaszak instructed staff to begin doing so immediately.
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On March 14, 2007, Staff 20 told the consultant that Administrator Mary Banaszak had
audited resident funds and told Staff 20 that the amount of cash on hand and the
balance on the Resident Funds Part II forms now balanced for all residents.
On March 15, 2007, the consultant received a preliminary Corrective Action Plan
addressing violations related to resident funds. The plan indicated that by March 15,
2007, Resident Funds Part II forms for all residents will be kept in a single binder.
Instructions for staff’s use of the binder will be placed in the staff Communicator as well
as in the lockbox used for resident funds. The lockbox will have $20 per resident (if the
resident has that available), and a count of the money in the lockbox will be made at
each shift change and recorded on a “check and balance sheet.” In addition,
Administrator Mary Banaszak will audit the funds and Resident Funds Part II sheets
twice a week.
On March 22, 2007, the consultant examined the Resident Funds Part II form for
Resident H and found that the resident had signed for a transaction which was blank,
meaning that the resident was not signing for transactions at the time they were
completed.
On March 22, 2007, the consultant examined the facility’s records and found that
Resident Funds Part II form for Resident C had been begun and showed deposits made
by the resident.
On March 20, 2007, ORR 1 reported to the consultant that Staff 7 had been terminated
because over the weekend she took resident money from the lockbox to purchase food
items to prepare a meal for residents in the facility. ORR 1 said that apparently staff do
not have access to any petty case to use to purchase items that might be needed in the
home when management is not present in the facility.
On March 22, 2007, the consultant received a phone call from and interviewed Staff 7.
Staff 7 reported that on Saturday, March 17, she had told residents that taco salad was
on the menu, but that all the ingredients weren’t available in the home. The meat was
available, but lettuce, seasoning, tomatoes and taco chips were not. Staff 7 said that
residents said they wanted taco salad. Staff 7 said she had been told a week or two
earlier by Administrator Mary Banaszak that if residents wanted something, staff should
go get it. Staff 7 said she had never before had access to cash in the lockbox. Staff 7
said she looked in the lockbox and took cash from an envelope of Resident D’s money,
went to the store and purchased the items required to make the taco salad. Staff 7 said
she put the receipt and a note regarding the purchase back in the lockbox. Staff 7 said
that it was her understanding that staff had used money from the lockbox before, and
that the home manager had reimbursed the funds from facility funds the next time the
home manager was in the facility. Staff 7 said there were no other petty cash funds
available. Staff 7 said she was not trying to take money from Resident D or any other
resident, and thought she was doing what she was supposed to do, in getting the items
to fix what the residents wanted to have. Staff 7 said that on other occasions she has
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brought food from home for residents, when there wasn’t something needed in the
home. Staff 7 said she also purchased pork chops for the evening meal. Staff 7 said
that tomato soup was on the menu, but three of the residents cannot eat tomato
products.
On April 3, 2007, the consultant conducted an onsite investigation in conjunction with
ORR 1. ORR 1 reported that she interviewed Resident D during this time. Resident D
said she asked for taco salad on Saturday, March 17, and told the staff to get her
money and get the stuff to make it. Resident D told ORR 1 that staff told her she didn’t
have enough money. Resident D told ORR 1 that she never complained that someone
took her money.
On April 3, 2007, Staff 19, the new Home Manager Interim, reported that she and Staff
2 now have access to petty cash, and that they also both have the use of a credit card
supplied by the licensee, so that purchases can be made to meet household or resident
needs.
APPLICABLE RULE
R 400.14315
Handling of resident funds and valuables.
(7) A resident shall have access to and use of personal funds
that belong to him or her in reasonable amounts, including
immediate access to not less than $20.00 of his or her personal
funds. A resident shall receive up to his or her full amount of
personal funds at a time designated by the resident, but not
more than 5 days after the request for the funds. Exceptions to
this requirement shall be subject to the provisions of the
resident's assessment plan and the plan of services.
ANALYSIS:
On more than one occasion, one or more residents had cash on
hand in the safe in the facility, and/or cash available according
to the Resident Funds Part II forms, but did not have $20 of their
funds available to them because the money was not in the
lockbox accessible to staff.
CONCLUSION:
VIOLATION ESTABLISHED
APPLICABLE RULE
R 400.14315
Handling of resident funds and valuables.
(3)
A licensee shall have a resident’s funds and
valuables transaction form completed and on file for each
resident. A department form shall be used unless prior
authorization for a substitute form has been granted, in writing,
by the department.
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ANALYSIS:
Despite having signed and submitted a Corrective Action Plan
indicating that all funds would be accounted for on the proper
forms, individual cash transactions for residents were not
properly recorded on Resident Funds Part II forms. No
Resident Funds Part II was completed for Resident C’s funds
until after the consultant reminded the Administrator of the
requirement.
CONCLUSION:
REPEAT VIOLATION ESTABLISHED [See Renewal
Licensing Study Report of November 16, 2006.]
ALLEGATION:
•
Staff are told by the home manager to fabricate outings and enter van mileage
anyway.
INVESTIGATION:
Staff 6 said he had never heard Staff 1 tell staff to fake an outing or alter any related
records. Staff 6 said he does not take residents on outings, because the residents
are all female and he wouldn’t be able to assist them in the bathroom. Staff 6 said
he does take Resident H to dialysis.
Staff 9 said that he has been working 3rd shift recently and doesn’t do resident
outings. Staff 9 said that he has never heard anything about staff doctoring the log
books or faking outings. Staff 9 said that he wanted to go on outings with residents
previously and was told that there wasn’t enough money.
Staff 4 said she has never heard of staff fabricating outings, and does not drive the
van herself.
Staff 10 said that no one has told her to falsify anything in the van log, because she
doesn’t drive. Staff 10 said, “But I know people do that, because they were told to
do that.” Staff 10 said she knew that a former staff person told her that Staff 1 told
her to just make up the stuff on the van log. Staff 10 said she thought this was
because the van log was in the house when staff took the van places. Staff 10 said
she didn’t think residents had been on any kind of outing for at least a month.
Staff 7 said that there are no outings in the home. When asked if staff are asked to
fake outings, Staff 7 said that there’s a sheet up on the refrigerator with activities and
outings that just started getting filled out, but that there is never any money or
enough gas in the van to take residents out. Staff 7 said that, for example, an outing
to Bingo across the street is scheduled, but there is never money to do that.
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On April 3, 2007, the consultant conducted an onsite investigation. The consultant
observed an Activity Calendar for the month of April posted on the refrigerator.
Residents reported that the previous day they had played cards, and “card games”
was one of the activities listed for April 2, 2007. The consultant asked residents
about activities listed on the March Activity Calendar, and all reported that none of
the activities or outings had occurred, except taking walks in the mall. Home
Manager Staff 19 reported that the home now has a calendar on which staff will
document the activities and outings that actually occur.
CSM 1 reported to the consultant that no resident in the home has outings or
activities specified in their Person Centered Plan.
Since outings were not specified in resident plans, no rule violation is alleged.
ALLEGATION:
•
Documentation in resident books is not kept up to date and documents are
forged.
INVESTIGATION:
2007, and found a note on the office door from Staff 1 to all staff “that instructed them to
complete their documentation (progress notes) from January.” CSM 1 noted that this
meant staff were not completing progress notes daily as required by CMH.
Progress notes are not required by the Administrative Rules. No rule violation is
alleged.
ALLEGATION:
•
There is evidence of mice and ants in the home.
INVESTIGATION:
allegations about the facility, one of which was that there were mice and ants in the
home.
10
On February 27, 2007, the consultant interviewed Resident A, who reported that she
and Staff 7 have seen mice in the facility before. Resident A said there are mice by the
washer and dryer, and in the office. Resident A said there is also a problem with ants in
the home. Resident A said that there are ants on the floor in her bedroom and some
have even crawled on her.
On February 27, 2007, Resident C said that there are mice under the kitchen counters
sometimes, and that she and Staff 6 saw them a few days earlier.
On March 20, 2007, ORR 1 told the consultant that Staff 11 reported that there were
ants in the kitchen and in the bathroom on the right side of the hallway. In the kitchen,
the ants are everywhere, and in the bathroom they’re around the drain.
Staff 11 reported that she has never seen mice in the facility but that Resident H pointed
out a mouse trap that’s between the washer and dryer in the laundry room.
On March 22, 2007, the consultant conducted an onsite investigation. The consultant
inspected the kitchen and laundry areas, and found no evidence of mice or ants. Staff
present at the time of the inspection reported that an exterminator comes regularly to
the facility and sprays. None of these staff had seen mice in the facility, but all of these
staff reported that ants are frequently in the kitchen near the sink, in the dining room
under the table, and in the laundry room around the drain. Staff reported that they had
been told the facility was sitting on top of an ant hill.
On April 3, 2007, the consultant conducted an onsite investigation. Staff at the facility at
the time, including Home Manager Staff 19, reported that the home has an active insect
and pest control program, and that the exterminator had serviced the facility on April 2,
2007.
APPLICABLE RULE
R 400.14401
Environmental health.
(5) An insect, rodent, or pest control program shall be
maintained as necessary and shall be carried out in a manner
that continually protects the health of residents.
ANALYSIS:
Multiple witnesses reported seeing evidence of ants or mice in
the facility. However, the facility has a documented ongoing
control program in place to protect the health of residents.
CONCLUSION:
VIOLATION NOT ESTABLISHED
11
ALLEGATION:
•
A resident was forced to take medication that had been dropped on the floor.
INVESTIGATION:
allegations about the facility, one of which was that a staff person had dropped a
medication on the floor, picked it up, and forced a resident to take it by holding the
resident’s face in the staff’s hand.
Staff 6 reported that “might have” given a resident a medication that had dropped on the
floor. Staff 6 said he didn’t want to waste the medication and didn’t think it would hurt
anything. Staff 6 said he did not force anyone to take a medication. ORR 1 told Staff 6
that any medication that falls on the floor must be disposed of and an Incident Report
written, since the medication is contaminated.
During the course of the investigation, the consultant and ORR 1 interviewed all
available residents and staff of the facility. No one reported experiencing, seeing, or
perpetrating the use of physical force by a staff person against a resident.
APPLICABLE RULE
R 400.14308
Resident behavior interventions prohibitions.
(2) A licensee, direct care staff, the administrator, members of
the household, volunteers who are under the direction of the
licensee, employees, or any person who lives in the home shall
not do any of the following:
(b) Use any form of physical force other than physical
restraint as defined in these rules.
ANALYSIS:
There is no evidence that a staff person used physical force
against a resident of the facility.
CONCLUSION:
VIOLATION NOT ESTABLISHED
ALLEGATION:
•
Residents are not receiving medications as prescribed.
INVESTIGATION:
allegations about the facility, several of which dealt with resident medications. ORR 1
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said she had received reports that prescriptions had not been filled timely, that staff
were not initialing Medication Administration Records at the time medications were
dispensed, that medications for several residents were in the same box, and that an
Epi-Pen required by Resident C was not present in the facility.
CSM 1 reported that there were several places on various resident Medication
Administration Records where staff had not initialed medications when given. CSM 1
reported that this is frequently what she observes when she reviews resident records in
the facility.
On February 22, 2007, the consultant conducted an onsite investigation. The
consultant observed that medications which were prescribed to be given three times
daily were being given at 8 AM, 4 PM, and 8 PM. The consultant advised the home
manager that this schedule did not space the medications evenly over the course of the
day.
On February 22, 2007, the consultant interviewed Nurse 1, who reported that vital signs
and weights are to be measured and documented for each resident of this home on a
weekly basis. Additionally, Resident D is to have her blood sugar level checked twice
daily before meals.
The consultant received and reviewed a document labeled as “Medication issues at
Rambo,” dated 2/12/07 and completed by Nurse 1. During the course of the interview
with Nurse 1 on February 22, 2007, Nurse 1 explained to the consultant that the
document was a record of her findings when she was at the facility on February 12,
2007, and checked medications. In the document, Nurse 1 noted the following:
• Resident H’s nasal spray was in Resident C’s medication box. Nurse 1 noted:
“(Resident C) also received nasal sprays, so these could have been mixed up
and Resident C could have received Resident H’s medication.”
• Resident F’s antibiotic ointment was in Resident C’s medication box, and was
expired.
• Two of Resident C’s medications were expired.
• A prescription for Resident H, dated 2/9/07, was tacked to the bulletin board and
had not been faxed to the pharmacy. The change ordered by the prescription
(an increase in dosage of a medication) had not been made.
• Several boxes on Medication Administration Records had not been initialed,
without explanation as to why the medications weren’t given, or if they were
given.
On February 26, 2007, the consultant interviewed Staff 6 in conjunction with ORR 1.
ORR 1 asked Staff 6 whose responsibility it was to check the whole medication process.
Staff 6 replied that he only passed medications. Staff 6 said that the former Medication
Coordinator used to keep staff up on a lot of stuff. Staff 6 said, “Now when the meds
come in I have to write it on the sheets myself. Meds come in on my shift, and I have to
hurry up and write it on, because you can’t pass meds that aren’t on the sheet.”
13
During interviews on February 26, 2007, both Staff 1 and Staff 20 told the consultant
that it was the Medication Coordinator’s job to review the Medication Administration
Records and make sure everything associated with medications is taken care of. Both
of these staff reported that the Medication Coordinator was terminated in January, and
that no one had filled that position. Staff 1 stated that all staff are taking turns, and
added, “I’m getting in on it, too.” ORR 1 reminded Staff 1 that it was her responsibility
as Home Manager to supervise the medication issues in the facility. Staff 1 said that
things were done as far as she knew.
On March 12, 2007, the consultant interviewed Licensee Designee Jamie BraggLovejoy by telephone. Ms. Bragg- Lovejoy reported that Staff 1, Home Manager, has
been dismissed. The Licensee Designee stated that she thought the medication error in
not getting certain prescriptions filled was the responsibility of Staff 1.
On February 22, 2007, the consultant examined the medication books in the facility. A
medication Check Sheet was in the front of each of two medication books, with a place
for date, time, and signature of the person dispensing medications. Another space for
time and the signature of the “Med Checker” completed each line. [Staff 2 informed the
consultant that the “Med Checker” is supposed to sign the sheet for each administration
of medication, according to the home’s medication protocol.] The consultant observed
that there were several empty lines where the “med checker” had not signed for the
med pass. On one page, for example, covering the period from January 9 through
January, with medications to be passed three times daily, only 12 signatures by the
medication checker were observed. The medication books also contained handouts
from two in-services conducted by Nurse 1. An item on one of these untitled handouts
noted: “Do not give medication that falls on the floor.” Each book also contained a copy
of an undated Medication Procedure from Saginaw County CMHA. [Nurse 1 informed
the consultant that this Medication Procedure is obsolete and should be removed from
the medication books.]
On March 14, 2007, the consultant examined medication records at the facility. The
consultant observed that the Medication Check Sheet in the front of each of two
medication log books had each time for medication administration already recorded, so
that staff (the medication passer and the checker) have only to sign the sheet after
completing the medication administration.
Due to the complexity and number of issues involved, findings regarding medications
are organized by resident below.
Resident A
Resident A’s file contained a copy of a prescription dated Wednesday, January 31,
2007, at 4:05 PM from St. Mary’s Emergency Care Center, for Bactrim DS 800 mg, to
be taken 1 tablet 2 times a day. 20 tablets were to be dispensed. This was treatment
for a urinary tract infection (UTI).
14
The consultant received and reviewed a copy of an Incident Report dated February 3,
2007, completed by Staff 1 and signed on February 7, 2007. According to the Incident
Report, Resident A’s father, Parent A, came to the facility around 9:45 AM on February
3, 2007, with the medication Sulfamethoxazole (generic for Bactrim) for Resident A.
Parent A wanted to Staff 4 to give Resident A the medication, but after conferring with
the Home Manager, Staff 4 told Parent A that he had to bring staff a copy of the written
prescription before the medication could be administered. Parent A then wanted to give
Resident A the medication himself. Staff called 911, and Parent A finally returned to the
pharmacy and got a copy of the prescription for the home files.
According to the resident’s Medication Administration Record for February (discussed in
detail below), the Bactrim prescription from St. Mary’s Emergency Care Center dated
January 31, 2007, was not given until the morning of February 4, 2007. No explanation
was available for why the medication was not administered until 3-4 days after the
medication was prescribed. The information on the Medication Administration Record
also contradicts the Incident Report completed by the Home Manager which indicated
that staff administered the medication when Parent A returned to the facility with the
required written copy of the prescription on the morning of February 3, 2007.
On February 26, 2007, Staff 6 told the consultant that he put the prescription in the
“script thing, a little plastic thing, where all the prescriptions that come in are supposed
to go.” Staff 6 said he had written in the Communicator so it could get filled, but when
he came back to work a day or two later, the prescription was still in the plastic holder
and had not been filled. Staff 6 said that Resident A’s father ended up getting the
prescription filled, and got angry because staff wouldn’t pass the medication without a
copy of the order.
The consultant received and reviewed a copy of correspondence wherein ORR 1 asked
an opinion from Nurse 2 regarding the potential impact of Resident A’s antibiotic
prescription not being filled (or administered) until at least three days after it was
received. Nurse 2 indicated that her judgment was that the failure to get the
prescription filled on time could cause or contribute to serious physical harm. Nurse 2
wrote that the untreated UTI could have led to serious complications including a kidney
infection or bacterial bloodstream infection.
The consultant reviewed two Incident Reports concerning medication refusals by
Resident A. No medical personnel were contacted for instructions, according to the
Incident Reports.
The consultant interviewed Nurse 1, who reported that the current medication protocol
supplied by Saginaw County CMHA to group homes instructs the home that staff should
contact a resident’s case manager or supports coordinator in the event of a medication
refusal. The consultant informed Nurse 1 that this was insufficient according to the
Administrative Rules. The consultant informed Nurse 1 and Administrator Mary
Banaszak that staff are to contact a health care professional and record and follow
instructions given every time there is a refusal of medications or a medication error.
15
The consultant examined Resident A’s Medication Administration Record pages for
January and February 2007 and found the following:
Resident A – January 2007 Medication Administration Record
MEDICATION
DOSE/INSTRUCTIO
ISSUE
NS
Depakote 250 mg.
1 tablet in AM
Not marked for 1/11, 1/14-16, 1/1819, 1/27. Nothing recorded in
Medication Notes on the back of the
MAR.
Depakote 500 mg
1 Tablet in PM
Not marked for 1/9, 1/12, 1/25.
Nothing marked in Medication Notes.
Flovent 220 mcg
Inhale 1 puff twice
Not marked 1/18, 1/19, 1/27 AM.
daily
Not marked 1/9, 1/25 PM.
3 doses circled, but no refusals or
other notes recorded.
Ferrous Sulfate 325
1 tablet twice daily
11 refusals noted on the back of the
mg
MAR in Medication Notes. No
indication that a health care
professional was contacted. No
instructions recorded. Nothing
marked at all on 1/4 AM, 1/9-1/10
PM. All other staff initials circled.
DC’d on 1/16/07.
Ibuprofen 800 mg
I tablet twice daily
7 doses initialed as given on the front
PRN
of the MAR, but only 5 doses
recorded in the PRN notes on the
back of the MAR. Reason for
administration not given. PRN dose
in Notes on 1/6 was entered after the
1/7/07 entry of a refusal of Ferrous
Sulfate. No indication that a health
care professional was contacted. No
instructions recorded.
Folic Acid 1 mg
Each of these medications was not
Haloperidol 2 mg
marked for the AM doses on 1/18,
Haloperidol 5 mg
1/19, and 1/27. Staff initials were
Loratadine 10 mg
circled for several doses of each of
Nystop 100,000u/mg
these medications during the month,
Oxybutynin 5 mg
with no explanations recorded on the
back of the Medication Administration
Oyst Cal D 500 mg
Record.
Phenobarbital 30 mg
Vit C 500 mg
Resident A - February 2007 Medication Administration Record – handwritten page
16
MEDICATION
Sulfamethoxazole
(generic for
Bactrim)
Folic Acid 1 mg
Haloperidol 1 mg
Haloperidol 0.5 mg
Haloperidol 0.5 mg
DOSE/INSTRUCTIONS
ISSUE
1 tablet twice daily
Prescription dated 1/31/07. Started
2/4/07 8 AM, according to the MAR.
Not marked for 2/4 PM.
Not marked 2/6 and 2/10 AM
1 tablet daily
Initials circled on 2/13, 2/16, and
2/24, but no explanation written.
Not marked on 2/17.
1 tablet daily
Started 2/11/07. Marked as being
given at both 8 AM and 8 PM from
2/11 onward.
Not marked 2/17 PM dose.
One dose on 2/13 circled, but no
explanation written on back.
1 tablet in the morning
Started 2/21 PM.
2 tablet in the evening
Circled 8 AM dose 2/24; no
for one week then stop. explanation.
1 tablet in the PM x 7
Marked 2/28 PM. [NOTE: This
days, then stop. Mar. 6 medication was not recorded on the
March Medication Administration
will be last dose.
Record. See March 7, 2007, Incident
Report noted above.]
Serious errors were noted in the handling of a change in Resident A’s Haldol
prescriptions. As of the end of January 2007, Resident A had been taking Haldol
according to the following schedule:
Haldol 2 mg tablet – 1 tablet in the morning
Haldol 5 mg tablet – 1 tablet at bedtime
Resident A’s Medication Administration Records for February included one handwritten page, noted above, and two pharmacy-provided Medication Administration
Record pages for February which were originally identical to the pharmacy-provided
Medication Administration Records for January. At the time the consultant obtained a
copy of these documents in mid-March, however, the type-printed inscription for the
Haloperidol 5 mg tablet (1 tablet at bedtime) had been altered, and “1/2” had been
written over the “5”. Thus, the entry read “Haloperidol ½ mg tablet” instead of
“Haloperidol 5 mg tablet.” The February Medication Administration Record showed that
this bedtime dose of Haloperidol was discontinued on 2/11/07. The Haloperidol 2 mg (1
tablet in the morning) dose was also discontinued, but as of 2/9/07.
The consultant obtained copies of the prescription orders for the February changes in
Resident A’s Haloperidol (e.g., Haldol). A prescription dated 2/9/07 ordered the
following:
• Stop Haldol 2 mg.
• Haldol 1 mg – 1 tablet every morning
• Haldol 5 mg – ½ tablet every evening.
17
A prescription dated 2/20/07 ordered the following:
• Decrease Halodol to 0.5 mg every morning x 7 days then D/C
• Decrease PM dose to 1 mg x 1 week, then 0.5 mg x 1 wk, then D/C
Thus, Resident A should have received Haldol according to the following schedule:
2/9 – 2/20
Haldol 1 mg 1 tablet every morning
Haldol 5 mg ½ tablet every evening
2/21 – 2/27 Haldol 0.5 mg1 tablet each morning
Haldol 1 mg 1 tablet each evening
2/28 – 3/6
Haldol 0.5 mg1 tablet each evening
According to Resident A’s February Medication Administration Records, however,
Resident A received a 1 mg tablet both AM and PM from February 11 through February
20 and on the morning of February 21. From February 21 PM through February 28,
Resident A received 0.5 tablet in the morning, and two 0.5 tablets in the evening (the
correct total dosage as prescribed). Resident A received no Haldol after February 28.
On March 7, 2007, Administrator Mary Banaszak faxed an Incident Report to the
consultant dated March 7, 2007. The Incident Report noted that Staff 2 had discovered
that Resident A did not receive her Haloperidol 0.5 mg for March 1 through March 6,
2007. The Incident Report noted that the medications were found in the bag containing
February medications, and had not been placed in the resident’s medication basket nor
transferred to the March Medication Administration Record.
On February 26, 2007, Staff 6 reported that Resident A’s parents had taken Resident A
to the doctor, and had given Staff 6 the prescriptions and told Staff 6 about the changes
to Resident A’s medication. Staff 6 said they wanted to wean Resident A off the Haldol.
Staff 6 said he didn’t know how the Haldol got left off the March Medication
Administration Record.
On March 9, 2007, the consultant interviewed ORR 1, who reported that she
remembered telling staff particularly to watch how Resident A’s Haloperidol was being
titrated. ORR 1 said that the physician was in the process of discontinuing this
medication for Resident A, and ORR 1 told staff to be especially careful in recording the
orders.
The consultant observed a copy of a prescription for Macrobid 100 mg, 1 tablet BID x 21
days, dated March 1, 2007. The consultant examined the corresponding Medication
Administration Record, and found that the prescription had been given when and as
prescribed.
Resident B
On March 13, 2007, the consultant conducted an onsite investigation and reviewed
resident records. The consultant observed a copy of a prescription in Resident B’s file
dated 2/28/07. The resident was prescribed Valium 5 mg – 2 tabs by mouth one hour
before an OB/GYN appt. scheduled for 3/12/07. Resident B went on a “leave of
18
absence” (LOA) visit with her father on 3/10/07 5 PM. A Leave of Absence Medication
Form in the resident’s file showed 2 tabs of each of the following medications were
given to the Responsible Person (Parent B – her father) by Staff 3:
Seroquel
400 mg
8 pm
Calcium
600 mg
8 am
Seroquel
100 mg
8 am
Fluoxetine 20 mg
8 am
Fluoxetine 10 mg
8 am
Buspirone 5 mg
8 am
Diazepam 5 mg
PRN
Nothing was written in the column for “Special Instructions” – and nothing was recorded
in the column for “Returned With”. Nothing was recorded under “Observations and
comments following LOA:” Nothing was recorded under “Medications taken as
directed?” No staff or manager signatures were recorded when the resident returned.
The March Medication Administration Record (MAR) showed “LOA” for Resident’s 8 PM
dose of Seroquel 400 mg on 3/10/07. All medications for 3/11 and 3/12 were marked as
LOA, except for the 3/12 8 pm dose of Seroquel 400 mg. The 4 pm dose of Buspirone
on 3/11 was circled. Staff 18 wrote on the back of the MAR that the 3/11 dose of this
medication was “not sent LOA still in pack.” Also marked on the back were the 3/10 2
tab Diazepam and 3/12 5 mg dose of Buspar as being sent “LOA with father”. [Thus,
not all medications sent on LOA were marked as such on the Medication Administration
Record, and one medication (4 pm Buspirone) was not sent at all.]
On March 15, 2007, the Licensee Designee submitted a preliminary corrective action
plan which indicated that an in-service would be held on March 15, 2007, instructing
staff how to properly complete an LOA with Medication form. A special file containing
all forms that need to be completed for an LOA will be made available to staff. The staff
who failed to send one of Resident B’s medications for her LOA was removed from the
schedule until the staff person repeats medication class through Saginaw County
CMHA. In addition, Nurse 1 will attend the March 15 staff meeting to speak on
medications.
A second March Medication Administration Record page for Resident B listed Calcium
with Vitamin D 600 mg. A “New Order” was recorded, to start 3/12/07 at 8 pm, for the
medication to be given 1 tab BID. The script was dated 3/5/07, and was faxed to the
house on 3/5/07. The new order was recorded on the MAR by Staff 18. Nothing was
marked for 8 PM on 3/12/07, which was when the medication change was written to
take effect, per Staff 18’s writing on the MAR.
Staff 18 told the consultant that when she and Administrator Banaszak and Home
Manager Staff 19 reviewed all the Medication Administration Records and medications
to assure that all was in order, they requested a written order for Resident B’s Calcium
with Vitamin D 600 mg. According to Staff 18, when they submitted the order dated
3/5/07 to the pharmacy, the pharmacy said it wasn’t a true prescription and did not fill
the prescription. Staff 18 acknowledged that they did have a written order from the
19
physician, and did have the pills in the facility, but failed to give the medication as
ordered because of the pharmacy’s insistence that it wasn’t a true prescription. Staff 18
had no explanation as to why this approval process took seven days (i.e., from 3/5/07 to
3/12/07).
Resident C
The consultant received and reviewed a document labeled as “Medication issues at
Rambo,” dated 2/12/07 and completed by Nurse 1. Nurse 1 noted that on February 12,
2007, when she was at the facility, Resident C’s Epi Pen [to be used in case of allergic
reaction to bee stings] could not be located in the medication closet. Nurse 1 said the
medication was not in Resident C’s box of medications.
On February 26, 2007, the consultant interviewed staff of the facility. Staff 6 did not
know what an Epi Pen was, nor did he know that Resident C had one. Staff 6 said he
would not know how to use one. Staff 9 did not know what an Epi Pen was, or how to
use it, or that Resident C had one. Staff 4 said that she had been told that if Resident C
got stung there was an Epi Pen, but that staff never saw the Epi Pen or knew that it was
in the medication closet.
On February 26, 2007, Staff 10 reported that she knew that the Epi-Pen was for
Resident C, in case she got stung by a bee.
On February 22, 2007, the consultant conducted an onsite investigation, in conjunction
with ORR 1. ORR 1 found Resident C’s Epi-Pen in its original box on a shelf in the
closet housing medications. The Epi-Pen was not with Resident C’s other medications.
During the onsite investigation, the consultant examined Resident C’s Medication
Administration Record and found the following:
MEDICATION
Geodon 80 mg
DOSE/INSTRUCTIONS
ISSUE
1 capsule twice daily, to Medication Administration Record
be taken with food at
indicates medication is given at 8 AM
breakfast and supper
and 8 PM. Bubble packs are marked
in the same manner.
On February 26, 2007, Staff 6 acknowledged that he had just seen on Resident C’s
Medication Administration Record that she was to be getting her Geodon with meals,
instead of when it had been being administered at 8 AM and 8 PM. Staff 6 said he just
noticed the day before our interview that someone had marked it with yellow. Staff 6
said, “I see somebody’s written on it now it should be passed with food.”
On February 26, 2007, Staff 4 reported that she called Staff 1 and told her that Resident
C had run out of her birth control pills. Staff 1 told Staff 4 that she didn’t know anything
20
about it and that Staff 4 should ask the other staff. Staff 4 said that she put her initials
with a circle around it on the Medication Administration Record, and that the next shift
staff called in the refill the next morning. Staff 4 said that Resident C missed
Wednesday’s and Thursday’s pills.
Resident D
On February 22, 2007, the consultant interviewed Nurse 1, who reported that Resident
D is to have her blood sugar level checked twice daily before meals.
On February 22, 2007, the consultant examined Resident D’s Diabetic Monitoring
Sheet. The sheet had no documentation that Resident D’s blood sugar was checked on
the following times:
2/3
8 AM
2/9
8 AM
2/18 4 PM
The notation, “Check blood Glucose before breakfast and before dinner” was on the
Medication Administration Record, but staff did not initial this as having been done at
least nine times during February.
On February 26, 2007, Staff 3 told the consultant that she had informed Staff 1 (Home
Manager) the day before (February 25, 2007) that they were out of glucose level test
strips for Resident D. Staff 3 said that Resident D’s blood sugar level was to be tested
in the morning, but Staff 1 didn’t bring the test strips to the facility until 3:00 PM.
The consultant received and reviewed a copy of an Incident Report signed by
Administrator Mary Banaszak and Staff 1 (Home Manager) on February 26, 2007,
reporting that Resident D did not get her blood glucose level checked on February 24,
2007 before dinner. The home had run out of testing strips. According to the Incident
Report, staff failed to inform Staff 1 that they were out of testing strips until February 25,
2007. Staff 1 wrote that she immediately went to the store and purchased testing strips,
and that the staff responsible for failing to report the absence of testing strips was given
a write-up.
2007, and checked Resident D’s records. CSM 1 reported that Resident D’s blood
sugar levels are to be recorded on a separate sheet and are supposed to be signed for
on the Medication Administration Record. CSM 1 wrote that there were 18 times in
February that staff recorded readings on the separate sheet but did not initial the
Medication Administration Record.
Resident E
On February 22, 2007, the consultant conducted an onsite investigation. The
consultant examined Resident E’s Medication Administration Records. Seroquel was
21
given as a PRN on 2/4/07, but nothing was recorded on the back of the Medication
Administration Record regarding the administration of the PRN. Resident E’s
Medication Administration Record indicated that vital signs were to be taken and
recorded weekly. According to the records examined by the consultant, no vitals for
Resident E were recorded for the weeks of 9/3/06, 9/24 – 10/25/06, 11/18-12/3/06, or
12/9/06 – 1/6/07.
On March 13, 2007, the consultant received and reviewed a written statement from
Nurse 1, dated March 7, 2007. Nurse 1 reported that Resident E had a urethral cyst
removed on March 6, 2007, and was given two prescriptions, one for an increase in
Ditropan and one for vaginal cream (along with a sample tube of cream to get started
immediately). Nurse 1 reported that Staff 1, who accompanied the resident to the
appointment, received written instructions from the physician for Resident E not to bathe
for 3-4 days due to the excision. Nurse 1 reported that when she arrived at the AFC
facility on the morning of March 7, 2007, she found the two prescriptions, the sample
tube of cream, and the physician’s written instructions still in Resident E’s chart. Nurse
1 reported that Staff 1 had thus failed to fax the prescriptions to the pharmacy, had
failed to start the vaginal cream at once, did not record the written instructions that
Resident E not bathe for 3-4 days, and did not record the Ditropan increase in dosage.
Nurse 1 recorded that Resident E did not received the prescribed cream on the evening
of March 6 or the morning of March 7. Nurse 1 reported that she worked with staff on
the morning of March 7, 2007, to take appropriate actions on the prescriptions and
physician instructions.
Resident F
According to the records examined by the consultant, no vitals for Resident F were
recorded for the weeks of 9/3/06, 9/24 – 10/25/06, 11/18-12/3/06, or 12/9/06 – 1/6/07.
Resident G
On February 22, 2007, the consultant examined Resident G’s records. Inspection of
documentation for Resident G’s vital signs revealed the following:
No vitals on 9/3/06.
No vitals between 9/25 to 10/24.
No vitals 11/25.
No vitals 12/9 (done) to 1/6(done)
Weekly vitals were marked on the Medication Administration Record – but not
initialed by staff except once in February.
Weights were sometimes recorded directly on the Medication Administration
Record. In one instance, the weight recorded on the Medication Administration
Record for Resident G was recorded the day before staff recorded weighing
Resident G on the Vitals Sheet, and two different weights were recorded.
22
The consultant examined Resident G’s Medication Administration Records and found
the following:
Resident G’s February 2007 Medication Administration Record
MEDICATION
DOSE/INSTRUCTIONS
ISSUE
Lamictal 150 mg
1 tab twice daily
Not marked 8 PM on 2/21.
Risperdal 1 mg MDissolve 2 tablets by
Not marked on 2/20.
Tab
mouth in the AM
On March 14, 2007, the consultant conducted an onsite investigation and examined
resident Medication Administration Records. Staff had initialed Resident G’s March
Medication Administration Record documenting that a PRN dose of Clonazepam 1 mg
was administered six times since the beginning of March: on March 3, 7, 8, 11, 12 and
14. The back of the MAR had seven doses listed, as follows:
Resident G – March 2007 Medication Administration Record Side 2, Medication Notes
Record for Clonazapam 1 mg – 1 tablet once daily PRN
Date
Time
Staff
3-3-07
None listed (4PM noted on front)
Staff 6
3-7-07
None listed (5PM noted on front)
Staff 6
3-8-07
None listed (11AM noted on front)
Staff 11
3-10-07
8 AM
Staff 4
3-11-07
8:30 (not specified AM/PM)
Staff 2
3-14-07
10:50 (not specified AM/PM)
Staff 2
3-12-07
4 PM
Staff 6
From these records, staff did not document the 3-12-07 4PM dose at the time the
medication was administered, since the 3-14-07 dose was entered before the 3-12-07
dose. Additionally, the 3-10-7 dose recorded in the “Medication Notes” on side 2 of the
Medication Administration Record was not recorded on the front of the Medication
Administration Record at all.
Resident H
On February 22, 2007, the consultant interviewed Nurse 1, who was at the AFC facility
during the consultant’s onsite investigation. Nurse 1 reported that Renagel 800 mg, for
chronic renal failure, was prescribed for Resident H on 2/9/07. Nurse 1 was at the
facility on 2/12/07 and found the prescription hanging on the bulletin board in the office.
Nurse 1 told staff the prescription needed to be dealt with immediately, so staff faxed
the prescription to the pharmacy. They received the prescription later that day and
started the medication at 5:00 PM on February 12. Nurse 1 told the consultant that she
doesn’t know why the prescription wasn’t filled immediately. Nurse 1 said she has told
23
the home that if they need to get a new medication and the regular pharmacy
(Advanced) is closed, they should go to Rite Aid or another 24-hour pharmacy and get
whatever is needed. Nurse 1 said that they can always transfer the prescription to
Advanced Care at another time. Nurse 1 also reported that Resident H’s weight and
blood pressure are to be taken daily and documented.
On February 22, 2007, the consultant noted that Resident H’s weight and blood
pressure readings were not being recorded daily on the Vitals/Weight Chart in the
resident’s file. Some readings were recorded directly on the Medication Administration
Record. The consultant noted that staff had recorded that the blood pressure cuff was
not working on February 22, 2007.
Resident H’s February 2007 Medication Administration Record
MEDICATION
DOSE/INSTRUCTIONS
ISSUE
Renagel 800 mg
Not marked for 5 pm dose on 2/14 or
2/20/07.
Garapentin 300 mg
Not marked for 2/20 or 2/21 8 PM
dose. [Note: the consultant checked
the bubble pack and found that these
two pills were not in the pack, and
that the corresponding bubbles had
been initialed and dated by Staff 6.]
Plan of Correction submitted
On March 15, 2007, the Licensee Designee submitted a preliminary corrective action
plan to address several of the issues related to resident medications and health care
noted in the findings above. A Med Passer/Checker form was revised to include all
medication times, to assure that staff sign for each medication pass. [A copy of this
revised form and the accompanying instructions were also given to the consultant.]
One-on-one training will be completed with the licensee’s staff nurse to observe staff in
passing medication.
The Corrective Action Plan also indicated that the Home Manager Interim [herein
referred to as Home Manager Staff 19] will assure that prescriptions will be date
stamped, and will be faxed to Advanced Care Pharmacy as received. If after hours, the
Home Manager Interim will assure that prescriptions are filled utilizing a 24-hour
pharmacy.
According to the Corrective Action Plan, the medication policies in place in the home will
be updated, taken from the most current Saginaw County CMHA Provider Manual, and
will be placed in the Medication Books. The Home Manager Interim will review the
Medication Administration Records at the start of her shift and note any and all
medication errors. The Medication Administration Records will be audited by another
24
administrative employee of the licensee at least three times a week to assure and
monitor compliance.
Follow-up
On April 4, 2007, the consultant conducted an onsite investigation to examine
medication records and to assess the licensee’s compliance with the preliminary
Corrective Action Plan. The consultant found the Medication Administration Records to
be current and properly completed. The Home Manager Staff 19 reported that she and
Staff 18 are auditing the Medication Administration Records regularly and that any
medication errors that may occur will be reported and corrected.
The consultant examined Resident H’s medication record. A prescription for an
antibiotic, dated 3/16/07, was received from the pharmacy and started on March 17,
2007.
APPLICABLE RULE
R 400.14310
Resident health care.
(1) A licensee, with a resident's cooperation, shall follow the
instructions and recommendations of a resident's physician or
other health care professional with regard to such items as any
of the following:
(a) Medications.
ANALYSIS:
Prescriptions ordered by the physician were not filled and
started promptly on at least three occasions: Resident H’s
Renagel, Resident E’s prescriptions following a cyst excision,
and Resident A’s antibiotic of January 31, 2007. The physician
instructions for Resident A’s Haldol prescription were not
followed.
CONCLUSION:
APPLICABLE RULE
R 400.14310
Resident health care.
(1)
A licensee, with a resident's cooperation, shall
follow the instructions and recommendations of a resident's
physician or other health care professional with regard to such
items as any of the following:
(d)
Other resident health care needs that can be
provided in the home. The refusal to follow the instructions and
recommendations shall be recorded in the resident's record.
25
ANALYSIS:
Staff did not take or record resident vital signs as directed by
Nurse 1. Resident D’s blood glucose levels were not always
taken and recorded as required.
CONCLUSION:
APPLICABLE RULE
R 400.14312
Resident medications.
(2) Medication shall be given, taken, or applied pursuant to label
instructions.
ANALYSIS:
Resident C’s Geodon was not given with food as instructed on
the label. The instructions for Resident A’s Haldol prescription
were not followed properly.
CONCLUSION:
APPLICABLE RULE
R 400.14312
(4)
When a licensee, administrator, or direct care staff
member supervises the taking of medication by a resident, he or
she shall comply with all of the following provisions:
(b)
Complete an individual medication log that
contains all of the following information:
(i)
The medication.
(ii)
The dosage.
(iii)
Label instructions for use.
(iv)
Time to be administered.
(v)
The initials of the person who administers the
medication, which shall be entered at the time the medication is
given.
(vi)
A resident's refusal to accept prescribed
medication or procedures.
26
ANALYSIS:
The initials of the person administering medications were not
always entered at the time the medication was given, and
sometimes were not entered at all on the Medication
Administration Records. Resident A’s refusals of medications
were not properly recorded.
CONCLUSION:
APPLICABLE RULE
R 400.14312
(4)
(c)
Record the reason for each administration of
medication that is prescribed on an as needed basis.
ANALYSIS:
Resident G received Clonazapam PRN several times in March,
but the reason for each administration was not recorded. Other
PRN medications were dispensed to other residents, without
reasons being recorded.
CONCLUSION:
APPLICABLE RULE
R 400.14312
(4)
(f)
Contact the appropriate health care professional if
a medication error occurs or when a resident refuses prescribed
medication or procedures and follow and record the instructions
given.
27
ANALYSIS:
The consultant found no record of a health care professional
(e.g., physician or nurse) being contacted in the event of
medication errors or refusals. Resident A’s Medication
Administration Records had several refusals indicted, but there
was no indication in the resident’s file that a health care
professional had been contacted. An Incident Report was
completed for some medication errors, but a health care
professional was not contacted, nor were instructions recorded.
CONCLUSION:
APPLICABLE RULE
R 400.14312
(6)
A licensee shall take reasonable precautions to
insure that prescription medication is not used by a person other
than the resident for whom the medication was prescribed.
ANALYSIS:
Nurse 1 documented finding at least one of both Resident F’s
and Resident H’s medications in Resident C’s medication box.
CONCLUSION:
APPLICABLE RULE
R 400.14312
(7)
Prescription medication that is no longer required
by a resident shall be properly disposed of after consultation
with a physician or a pharmacist.
ANALYSIS:
Nurse 1 documented finding expired medications in residents’
medications boxes.
CONCLUSION:
ALLEGATION:
•
The home manager is rude to residents and uses an unacceptable tone of voice.
INVESTIGATION:
28
Staff 6 said that he has never heard Staff 1, the home manager, yelling at residents.
Staff 6 said that Staff 1 always keeps the same tone of voice.
During the course of the investigation, the consultant and ORR 1 interviewed all
available staff and residents. No one reported that Staff 1 yelled at residents.
Resident A told the consultant that Staff 2, 4, and 9 are not nice to her. Resident A
said that Staff 9 yells at her and tells her she needs to walk with her walker and get
her own glass of water. Staff 4 wakes Resident A at 10 AM to take her medicine,
but does so by knocking on the resident’s bed. Resident A said, “I don’t need that
kind of rude awakening.” Resident A said that Staff 2 will go to the store to get
things for other residents, but refused to get Resident A some Doritos because she
said they weren’t on the resident’s plan. Resident A said that Staff 10 and 12 offend
her by covering up their noses, using their shirts over their faces, when they are
caring for Resident A’s colostomy. Resident A said she knows that it smells, but
staff’s behavior offends her.
On February 27, 2007, the consultant interviewed residents of the facility, in
conjunction with ORR 1. Resident G and Resident H said they do not get along with
Staff 4. Resident H said, “She (Staff 4) said, ‘Why don’t you go mind your own
goddamned business!’ That’s why I don’t get along with her.”
Resident E said that staff sometimes use words they shouldn’t. Resident E said that
Staff 9 uses cuss words sometimes, but that Staff 4 uses cuss words every day.
Resident C reported that Staff 4 is mean to almost everybody, but especially to
Resident A, and that Staff 4 uses bad language. When asked if any staff were being
overly rough or mean, Resident C again said that Staff 4 was, with Resident A and
sometimes with Resident H. Resident C said that Staff 1 is generally nice, but not to
Resident A. Resident C said that Staff 1 says inappropriate things to Resident A,
but did not give any examples.
APPLICABLE RULE
R 400.14304
Resident rights; licensee responsibilities.
(1)
Upon a resident's admission to the home, a
licensee shall inform a resident or the resident's designated
representative of, explain to the resident or the resident's
designated representative, and provide to the resident or the
resident's designated representative, a copy of all of the
following resident rights:
(o)
The right to be treated with consideration and
respect, with due recognition of personal dignity, individuality,
and the need for privacy.
29
R 400.14304
Resident rights; licensee responsibilities.
(2)
A licensee shall respect and safeguard the
resident's rights specified in subrule (1) of this rule.
ANALYSIS:
There is evidence that staff have used inappropriate language
with residents. Staff treatment of Resident A when providing
personal care has sometimes been disrespectful.
CONCLUSION:
ALLEGATION:
•
Toilet paper is not always available.
INVESTIGATION:
On February 22, 2007, in the late afternoon, the consultant conducted an onsite
investigation in conjunction with ORR 1. The following was observed:
• The “shower” bathroom had no toilet paper available. A very strong urine odor
was present. The cover of the overhead light/fan combination was full of bugs.
• No toilet paper was available in the “tub” bathroom.
On February 22, 2007, Staff 7 reported that she had put the last two rolls of toilet paper
in the bathrooms the previous evening. Staff 7 said that the home frequently runs out of
toilet paper.
2007, in the late morning. CSM 1 reported that while she was there, Resident D had
asked staff for toilet paper for another resident who was in the bathroom, and that staff
ignored the resident and did not give her any toilet paper. CSM 1 reported that when
she used the restroom later in the morning, she had to ask staff for toilet paper and
paper toweling, because neither were present in the bathroom.
On February 27, 2007, Resident D reported that she did ask staff for toilet paper one
day when CSM 1 was at the facility, but that staff never gave her any.
On February 26, 2007, Staff 6 reported that hey run out of toilet paper a lot. Staff 6 said
he has brought detergent in when they were out of it in the AFC home, and that he was
paid back.
30
On February 26, 2007, Staff 9 reported that he has been working when the house had
run out of toilet paper. Staff 8 said that the home is frequently out of cleaning and
laundry supplies.
On February 26, 2007, Staff 4 said that they frequently run out of toilet paper. Staff 4
said that Staff 1 might bring in 4 rolls, which might last a couple of days. Then staff
have to call her and ask for more again. Staff 4 said that Staff 1 said that the staff are
using up cleaning supplies too quickly and that she (Staff 1) is only going to buy stuff
from the dollar store.
On February 26, 2007, Staff 10 said that the home runs out of toilet paper every other
week.
On February 26, 2007, Staff 11 said that toilet paper has been the issue within the last
six months. Staff 11 said that at least three times they’ve run out. Staff 11 said that this
was her sixth day in a row working. Staff 11 said that there was no body wash for the
residents on Friday, Saturday, or Sunday (February 23, 24, or 25). Staff 11 said that
Resident A’s parents brought in 3 bars of Ivory soap, and staff took one bar to give the
other residents to use. Staff 11 said that she worked the 1st shift on February 21 and
Resident H took a shower that day, but hasn’t taken one since because she won’t use
someone else’s soap or body wash. Staff 11 said that only shampoo and conditioner
have been available, and that some residents have been washing with shampoo. Staff
11 said that one day in January she came to work and there was no toilet paper, no
paper towels and no food. Staff 1 wouldn’t answer her phone. When Staff 1 finally did
answer the phone, Staff 11 told her that something had to be done NOW. Staff 1 came
to the facility in about 15 minutes and brought one roll of toilet paper, one roll of paper
towels, and one package of meat. Staff 11 said that before Staff 1 brought the stuff, she
told Staff 11 to use the brown paper towels for toilet paper. Staff 11 said, “I told her
NO!”
On February 26, 2007, Staff 2, 3, 5 and 12 all reported that Staff 1 once brought in two
rolls of paper towels when staff had called to report that the home was out of toilet
paper. Staff 1 told them to use the paper towels until she could get some toilet paper at
the store.
On February 26, 2007, the consultant interviewed Staff 20, who is the “Quality
Assurance Manager” for the licensee. Staff 20 said that the home has not run out of
toilet paper, but that the toilet paper is locked up because Staff 1 felt that staff were
stealing supplies. Staff 20 said that Staff 1 would buy soap for the residents on Friday,
and by Monday it would be gone.
On February 27, 2007, the consultant interviewed residents of the facility, in conjunction
with ORR 1. Resident H said, “Sometimes we don’t have no toilet paper.” Resident G
said, “I went to use the toilet one time and there was no toilet paper, and there was
poop on the seat and on paper in the waste basket.”
31
On February 27, 2007, Witness 1, a former staff person, reported that one weekend
when she was still working at the facility, they ran out of toilet paper. Staff 1 told staff to
use napkins instead. Later that day Staff 1 brought in 4 rolls of toilet paper. [Note: there
are two bathrooms, 8 female residents, and at least two staff per shift in this facility.]
APPLICABLE RULE
R 400.14305
Resident protection.
(3) A resident shall be treated with dignity and his or her
personal needs, including protection and safety, shall be
attended to at all times in accordance with the provisions of the
act.
ANALYSIS:
By failing to assure that toilet paper, other personal hygiene
products, and cleaning products were available for residents’
use, the licensee failed to treat residents with dignity and did not
attend to their personal needs.
CONCLUSION:
ADDITIONAL FINDINGS
ALLEGATION:
•
Linens are inadequate in the facility.
INVESTIGATION:
On February 22, 2007, in the late afternoon, the consultant conducted an onsite
investigation in conjunction with ORR 1. The following was observed:
• In Resident F’s bedroom, one bed had only a mattress pad, a bottom sheet, and
a spread. The other bed had no mattress pad.
• In the bedroom shared by Residents E and G, neither bed had a mattress pad.
One bed had no pillow or blankets.
• Resident H’s bed had no sheets.
• Pillow shams were being used as pillow cases on some bed pillows.
Staff 7 said that there are not enough mattress pads and linens in the house for all the
residents when some things are in the laundry.
Staff 9 said that he knows there are not a lot of extra linens and things like mattress
pads. Staff 9 said, “I know that much because I do the laundry.”
32
On February 26, 2007, Staff 12 reported that Resident E’s sister bought Resident E a
mattress pad, because there wasn’t one for her bed.
APPLICABLE RULE
R 400.14410
Bedroom furnishings.
(5)
A licensee shall provide a resident with a bed that
is not less than 36 inches wide and not less than 72 inches long.
The foundation shall be clean, in good condition, and provide
adequate support. The mattress shall be clean, comfortable, in
good condition, well protected, and not less than 5 inches thick
or 4 inches thick if made of synthetic materials. The use of a
water bed is not prohibited by this rule.
ANALYSIS:
The consultant, ORR 1, and other witnesses observed that
resident mattresses were not always well protected.
CONCLUSION:
APPLICABLE RULE
R 400.14411
Linens.
(1)
A licensee shall provide clean bedding that is in
good condition. The bedding shall include 2 sheets, a pillow
case, a minimum of 1 blanket, and a bedspread for each bed.
Bed linens shall be changed and laundered at least once a
week or more often if soiled.
ANALYSIS:
During the onsite inspection on the afternoon of February 22,
2007, various beds were observed to be missing sheets, pillows,
pillow cases, spreads, or blankets.
CONCLUSION:
ALLEGATION:
•
Staff fail to cooperate with residents and residents’ families.
33
INVESTIGATION:
2007, in the late morning. CSM 1 reported that while she was there, Resident D had
asked staff for toilet paper for another resident who was in the bathroom, and that staff
ignored the resident and did not give her any toilet paper. CSM 1 also reported that
Resident A asked for help to wash her face while CSM 1 was in the facility, and staff
“kind of ignored her.” CSM 1 wrote that she wasn’t sure if Resident A ever did get
assistance from staff.
The consultant received and reviewed a Progress Note completed by CSM 2 on
February 20, 2007, reporting that Resident H was a “no show/no call for missed
appointment today, 2/20/07.”
ORR 1 informed the consultant that Resident H was scheduled for therapy on February
20, 2007, but that staff failed to take the resident to the appointment.
On March 13, 2007, the consultant received and reviewed a copy of a Progress Note
written by CSM 1 and dated March 6, 2007. CSM 1 reported that she had received a
phone call from Resident B’s father, Parent B, with concerns about the facility. Parent B
stated that he went to the facility on Friday, March 2, around 5 PM to pick up Resident
B. Parent B said he had called the facility an hour and a half prior to coming so that
staff could have Resident B ready to leave for a home visit when he arrived, but Parent
B had to wait for over an hour while staff put Resident B’s medications in envelopes and
marked each one. Parent B told CSM 1 that he thought staff slowed down even more
after he asked what was taking so long.
On April 18, 2007, the consultant interviewed Parent B. Parent B told the consultant,
“The only hassle I had was that I had to wait for over an hour to get my daughter one
day, even after I had called ahead.” Parent B said that when he arrived at the facility,
staff were putting each of Resident B’s medications in an envelope, writing down the
instructions, etc. Parent B said the facility now has pharmacy bottles that are used for
Resident B’s medications for LOAs, and that this is working much better.
The consultant received and reviewed a copy of an Intervention Report completed by
ORR 1 on March 7, 2007. According to the report, someone from Resident C’s place of
employment filed a complaint on Resident C’s behalf, that Resident C had been late for
work on more than one occasion for reasons which were not of the resident’s doing.
ORR 1 determined that staff failed to get Resident C to work on time. ORR 1 recorded
that she made contact with Staff 20, in the absence of the home manager, who agreed
that every effort will be made to get Resident C to work on time, and that instances
when Resident C is or will be late will be recorded and reported to the Office of
Recipient Rights.
34
APPLICABLE RULE
R 400.14201
Qualifications of administrator, direct care staff, licensee,
and members of the household; provision of names of
employee, volunteer, or member of the household on parole
or probation or convicted of felony; food service staff.
(11) A licensee, direct care staff, and an administrator shall be
willing to cooperate fully with a resident, the resident's family, a
designated representative of the resident and the responsible
agency.
ANALYSIS:
By ignoring Resident D when she requested toilet paper, by not
having Resident B’s medications ready for the resident to leave
with Parent B when given advance notice, and by not getting
residents to appointments on time, staff failed to cooperate fully
with residents, responsible agency staff, and family members.
CONCLUSION:
ALLEGATION:
• Staff are not providing personal care.
INVESTIGATION:
On February 27, 2007, the consultant interviewed Resident A. Resident A reported that
she fell out of bed on Saturday, February 24, 2007, and no one would help her up.
Resident A said this occurred in the morning on first shift. Resident A said she thought
Staff 2 and Staff 4 were working that morning. Resident A said that Staff 7 wouldn’t
help her on second shift either. Resident A said, “My concern is, when I have a mess,
they always tell me, ‘You got to wait a minute, we’re eating.’”
The consultant reviewed Resident A’s Resident Assessment Plan in the resident’s file.
The plan indicated that Resident A required assistance with toileting, bathing, and other
personal care.
On March 13, 2007, ORR 1 reported that she had substantiated violations of Resident
A’s rights when staff called Resident A’s mother to come to the facility and provide care
because they did not know how to care for the resident’s ostomy bag. ORR 1 said that
Resident A’s ostomy bag had come off, and staff did not know how to re-attach it.
Resident A’s mother did come to the facility, and when she asked staff to assist when
she was giving the resident a shower, staff did not assist. The consultant also received
35
and reviewed the Report of Investigative Findings for this complaint, which
substantiated violation of rights by Staff 2 and Staff 7for failing to assist Resident A with
personal care.
The consultant received and reviewed a copy of an Incident Report about events on
January 27, 2007. The Incident Report was signed by the Home Manager and by
Administrator Mary Banaszak on February 7, 2007. According to the report, about 7:30
PM, Resident A stepped on her catheter bag and pulled it out. The report indicated that
staff called the Home Manger, who told them to contact Resident A’s mother to come
and replace the bag. If the mother couldn’t come, staff were to call 911. The report
noted that Resident A’s mother did come to the facility and replace the catheter bag.
The consultant received and reviewed written statements from Staff 2, 6, and 7
reporting events that happened on January 27, 2007. According to the statements,
Resident A had been sitting at the dining room table, then went to her room. Shortly
thereafter, another resident came out with Resident A’s colostomy bag. Staff found
Resident A on her bed, and then called the Home Manager. Staff then gave Resident A
the phone so Resident A could call 911, but Resident A called her mother instead.
Resident A’s mother came to the facility and changed the colostomy bag. She also
gave her daughter a shower, and asked staff for assistance. Resident A’s mother told
staff they should have been able to re-attach the bag themselves, and staff told her that
they had not been trained to do that. Staff told Resident A’s mother that there was an
extension on the shower handle so that Resident A could shower herself. There were
words between Resident A’s mother and staff before Resident A’s mother finally left the
facility. Staff reportedly offered to assist Resident A at this point, but she declined help.
On February 26, 2007, Staff 9 stated that if Resident A’s catheter came out, he would
call the Visiting Nurse, and if he couldn’t make contact there, he would call 911.
On February 26, 2007, Staff 4 said that there are always supposed to be two staff
assisting Resident A when needed, because one staff person can’t do it alone. ORR 1
asked how many staff were left to supervise and assist other residents if two staff
persons were assisting Resident A in the shower, and Staff 4 said, “One, IF there are
more than 2 staff here to start with!” Staff 4 said that sometimes there might be only
one staff on duty for an hour or so, but that this only happened a couple of times. Staff
4 said that about two weeks ago, she was there by herself. Staff 4 said she called Staff
1 and reported this, and she said, “You can handle it.” Staff 4 said that this was
between 7:30 and 8:30 AM, and that Staff 1 came into work between 9 and 9:30 that
morning. Staff 4 said she had to pass medications during the time that she was working
alone in the facility. Staff 4 said that sometimes when she’s working it’s only her and
Staff 1 on duty. Staff 4 said that Staff 1 says she’s going to help with resident care, but
that Staff 1 really stays in the office.
On February 26, 2007, Staff 7 reported that they have been having just two people on
the first shift each day, and that even on Saturday, February 24 (when all the residents
36
are home), there were only two people on first shift. Staff 7 said that Staff 1 said this
was because the home was short-staffed.
On February 26, 2007, Staff 2, 3, 5 and 12 all reported that only two people are working
each shift now. They reported that this occurred on February 20, 25, and 26, as
examples. These staff stated that at first they thought the home was just short-staffed,
but that now staff are sometimes being asked to work double shifts also.
The consultant received and reviewed a copy of the facility schedule for March 17
through March 30, 2007. The consultant specifically examined the staffing levels for
Monday, March 19, and for Saturday, March 25, 2007. For both days, three staff were
scheduled to be on duty except during the midnight shift, when two staff were
scheduled.
On April 17, 2007, the consultant interviewed Parent B, who stated that Resident B
doesn’t clean her personal areas and cannot shave her armpits. Parent B said that he
has had to shave Resident B’s armpits sometimes when she comes home for the
weekend. Parent B said he had spoken to Resident B’s case manager, and that the
case manager was supposed to address this issue with staff, because staff at the home
should be shaving Resident B as part of her personal care.
APPLICABLE RULE
R 400.14303
Resident care; licensee responsibilities.
(2) A licensee shall provide supervision, protection, and
personal care as defined in the act and as specified in the
resident's written assessment plan.
ANALYSIS:
Staff did not provide the personal care specified for Resident A
and Resident B.
CONCLUSION:
ALLEGATION:
• Menu substitutions are not being recorded.
INVESTIGATION:
On February 22, 2007, the consultant conducted an onsite investigation in conjunction
with ORR 1. The consultant and ORR 1 observed that menu substitutions were not
recorded on the menu on the refrigerator. The consultant and ORR 1 noted that the
posted menu did not list the same items that residents and staff reported as having
been served that day or the previous day.
37
On February 26, 2007, Staff 6 told the consultant that some days staff don’t have the
food they need to prepare what’s on the menus, so they have to prepare something
else. Staff 6 said that some of the staff “don’t know about that you have to write down
substitutions.” Staff 6 said that Staff 1 told some staff, but that they have a lot of new
staff, too, who don’t know a lot of the rules.
On February 26, 2007, Staff 7 reported that she has brought food from home for the
residents. Staff 7 said that Staff 1 only buys food for three days at a time, and not
everything that’s on the menu for those days. Staff 7 said that there’s no reason for
staff to steal the food, and that staff are supposed to eat with the residents. Staff 7 said
that there isn’t enough food in the house, and that staff can’t follow the menu.
Staff 9 said that the food supply “hasn’t been plentiful.” Staff 9 said that a couple weeks
prior to the interview, “there wasn’t much to eat.” Staff 9 said that he cooks in the
mornings, since he primarily works third shift. Staff 9 said that about 50% of the time he
can’t follow the menu and has to make substitutions. Staff 9 said that he writes the
substitutions on the list on the refrigerator door.
Staff 10 said that there isn’t enough food for 8 people, and that they haven’t usually had
the food needed to prepare what’s on the menu. Staff 10 said that she thinks residents
know that staff are doing the best they can. Staff 10 said that a lot of times the second
shift staff have had to go to the grocery store to get food out of their own pockets, or
they’ll bring food from their own house. Staff 10 said that the staff don’t get reimbursed.
On February 26, 2007, Staff 11said that the menu on the refrigerator lists what you’re
supposed to fix, but that what you need is not in the cabinet or freezer or refrigerator, so
you have to substitute what IS there. Staff 11 said that staff are not allowed to write
their substitutions on the menu, though. Staff 11 said there is enough food to give all of
the residents one serving usually, but that there isn’t enough for second helpings. Staff
11 said that Resident G and Resident B are big eaters, and that if they take what they
want, then that’s taking from someone else.
On February 26, 2007, Staff 4 said that on the day before (February 25, 2007), Resident
A’s father brought take-out food for Residents A, C, and H. Staff 4 said that the menu
called for chicken tortillas, but there weren’t tortillas in the house and there wasn’t
enough lettuce and tomato. Staff 4 said there were nacho chips, a little bag of chicken
strips, a quarter of a head of lettuce, and one tomato. Staff 4 said that if everyone had
eaten, there wouldn’t have been enough. Staff 4 said that if she had called Staff 1, “she
would have said that I had to work with what was there.” Staff 4 said that Staff 1
claimed staff were taking food.
On February 26, 2007, Staff 1 said that it wasn’t true that staff didn’t record
substitutions. Staff 1 said, “There are substitutions on there.” Staff 1 said she bought
what was on the menu, and that there is always extra food. Staff 1 said that she thinks
staff were used to someone buying what the staff wanted, and she doesn’t do that.
38
On April 2, 2007, the consultant conducted an onsite investigation and observed that
menu substitutions, when made, were being recorded on the menu.
APPLICABLE RULE
R 400.14313
Resident nutrition.
(4)
Menus of regular diets shall be written at least 1
week in advance and posted. Any change or substitution shall
be noted and considered as part of the original menu.
ANALYSIS:
On at least some occasions, menu substitutions were not
recorded.
CONCLUSION:
ALLEGATION:
• The licensee accepted and retained a resident for whom the facility could not
provide adequate care.
INVESTIGATION:
According to the facility’s Resident Register, Resident A was admitted to the facility on
November 16, 2006.
On February 27, 2007, Resident C told the consultant that she doesn’t like sharing a
room with Resident A, because the room smells bad all the time. Resident C says she
knows that it’s not Resident A’s fault, but that Resident A’s ostomy bags and other
hygiene issues just mean there’s always a smell.
On February 27, 2007, ORR 1 told the consultant that the AFC facility does not have a
van with a wheelchair lift, and Resident A must be transported in her wheelchair.
Additionally, Resident A does not have a private room in the facility. Resident C,
Resident A’s roommate, must deal constantly with the odors from Resident A’s
urostomy and colostomy.
On March 20, 2007, Licensee Designee Jamie Bragg-Lovejoy told the consultant that a
discharge notice would be issued to Resident A, because the facility could not provide
the services required.
39
APPLICABLE RULE
R 400.14301
Resident admission criteria; resident assessment plan;
emergency
admission;
resident
care
agreement;
physician’s instructions; health care appraisal.
(2)
A licensee shall not accept or retain a resident for
care unless and until the licensee has completed a written
assessment of the resident and determined that the resident is
suitable pursuant to all of the following provisions:
(a)
The amount of personal care, supervision, and
protection that is required by the resident is available in the
home.
(b)
The kinds of services, skills, and physical
accommodations that are required of the home to meet the
resident’s needs are available in the home.
c
The resident appears to be compatible with other
residents and members of the household.
ANALYSIS:
Resident A requires the use of a vehicle with a wheelchair lift for
transportation. In case of emergency, the facility would be
unable to remove Resident A from the facility to another
location. Resident A is incompatible with other residents of the
facility, especially her roommate, due to her lack of hygiene.
CONCLUSION:
LICENSEE DESIGNEE RESPONSE
On March 20, 2007, the consultant received a telephone call from Licensee Designee
Jamie Bragg-Lovejoy. Ms. Bragg-Lovejoy wanted to confirm the consultant’s receipt of
a plan of correction noted previously in this report. Ms. Bragg-Lovejoy stated that she
thinks that the plan, plus Administrator Mary Banaszak’s presence at the facility, will
address the issues in the current investigation.
On April 23, 2007, the consultant conducted a final exit conference with Licensee
Designee Jamie Bragg-Lovejoy. Ms. Bragg-Lovejoy stated that an individual has been
hired to provide additional administrative oversight to this facility and its management
and administrator. The consultant informed the Licensee Designee about the findings
and violations cited in this report. Ms. Bragg-Lovejoy told the consultant that she would
carefully review the written report when received, but said she did not disagree with the
consultant’s conclusions. Ms. Bragg-Lovejoy stated that she would respond promptly
with a written corrective action plan, and would continue to do whatever necessary to
assure that the facility achieves and maintains compliance with the Act and
administrative rules.
40
IV.
RECOMMENDATION
Since the licensee has taken immediate action to correct some violations cited in
this report, and since the licensee has made administrative changes in an attempt to
achieve compliance and assure continuation of the same, I recommend that the
status of this license remain unchanged, pending the receipt of an acceptable
corrective action plan. I further recommend that the facility be placed on a plan of
enhanced supervision for a period of six months, which may include announced and
unannounced inspections.
April 26, 2007
________________________________________
Diane L Stier
Date
Licensing Consultant
Approved By:
4/26/2007
________________________________________
Jack R. Failla
Date
Area Manager
41

On letterhead

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