Centennial Healthcare And Rehabilitation Center (April 12, 2012)
According to interviews with staff, observations, policy review and clinical record review it was determined that the nursing facility failed to conduct interdisciplinary assessments to evaluate a resident’s ability to safely administer medications for one of 26 residents. Those finding included the following: facility policy titled, Medication Administration, Self, dated January 1, 2011, revealed that residents may self administer his/her medications if the interdisciplinary team has determined that this is a safe practice and that a resident would have a physician’s order permitting a resident to administer their own medications, which included herbal supplements and vitamins. During the initial tour of the facility on April 9,2012, at 9:25a.m., Resident R148 was observed to have pill bottles of Juice Place Orchard Blend and Juice Plus Garden Blend on bed side table. In an interview with an employee, it was confirmed that staff were not aware of the resident taking over the counter herbal medication. In a clinical review dated April 9,2012 it was revealed that there was no physician’s order for the supplements or permitting self medication. The facility failed to follow their policy regarding self administration and ensure Resident’s R148’s compliance.
Based on interviews with residents, staff and a review of clinical records, it was determined that the nursing home failed to ensure that individual needs of residents were met to operate the lights independently, or to assistive devices to residents with vision limitations. Those findings included the following: In an interview with Resident 10 on April 11, 2012 at 1:00 p.m., revealed that she was unable to operate her overbed light without getting out of bed to her wheelchair, crossing the bedroom to the light switch on the wall at the entrance to the bedroom. Upon observation of the overbed light in bedroom 204, window bed at the time, found no pull attached to the light. The information was shared with maintenance Employee E5. An observation of the 204W overbed light on April 12, 2012 at 1:00p.m., revealed that she was unable to operate her overbed light without getting out of bed to her wheelchair, crossing the bedroom to the light switch on the wall at entrance to the bedroom. In observation of the overbed in bedroom 204, the window bed at the time found no pull cord attached to the light. This information was also shared with maintenance Employee E5. In an observation of the 204W overbed light on April 12, 2012, at 11:00a.m., the employee found a pull cord attached to the overboard light, but the cord did not function to turn the light on or off. The finding was confirmed in an interview with maintenance Employee 5 on April 12, 2012 at 11:05 a.m.
In an interview with Resident 22 during a group meeting on April 9, 2012 it was revealed that the pull cord did not function to operate the light fixture. Review of the clinical record for Resident R38 revealed a quarterly Minimum Data Set dated February 16, 2012 that indicated that this resident was admitted to the facility and this resident requires corrective lenses. Further clinical review revealed an ophthalmic examination, dated October 31, 2011 with the recommendation of bifocal glasses for this resident. In an interview with Resident 38, at 10:30 a.m. on April 10, 2012, she indicated that she had eyeglasses when she entered the facility, but that they had broken not long after she entered the facility.