Facility Evaluation Report

On 10-16-24 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding previously reported incident involving medication and restraint practices. LPA met with Administrator Danica Morrison and explained the purpose of the visit. LPA conducted brief interview with Administrator and reviewed incident reports dated 9/10/24 and 10/3/24. LPA also reviewed individualized program plan (IPP) for resident2 (R2).

Incident #1: Based on interview and record review, on 9/10/24 it was discovered by facility that multiple medications for resident1 (R1) which included Clonidine HCL 0.1mg, Lactulose 10mg/15mL, and Psyllium Husk 100% powder were not given by Staff1 (S1) to R1 per Physician's orders on 9/9/24. Record review also states medication log sheets indicated medication was not given. It was revealed that facility staff notified R1's Physician accordingly and followed additional instructions given. Incident report reviewed revealed staff member missed giving medication to R1 due to an "oversight."

Incident #2: Based on interview and record review, on 10/3/24 at approximately 3:45pm, R2 engaged in high risk behavior which included grabbing, swinging, and spitting at staff. Staff on duty attempted to redirect R2 to another room but were unsuccessful. S2 attempted to verbally redirect R2 but was unsuccessful and R2 continued behaviors of hitting and spitting at staff. Interview and record review revealed S2 then lifted R2 up and escorted R2 out the front door of facility. Facility staff on duty notified Administrator and Physician. Staff received and followed additional instructions from Physician. R2 was not injured during the process of this transfer procedure. It was determined through interview that this lift procedure was not an approved procedure according to training and facility protocol. Additional record review revealed S2 received proper training on de-escalation and crisis prevention intervention prior to this incident.

Additional incident reports were reviewed by LPA during this visit regarding R2 and on-going behaviors exhibited at facility. Incident reports include the dates of 9/4/24 and 9/5/24 and described behaviors exhibited by R2 as hitting, spitting and yelling at staff. {Cont. on 809C}