| 6400.72(b) | At 10:58AM, there was a ten inch by two inch by two inch rectangular rip in the screen in the window on the left side of Individual #1's bedroom. There was multitude of small holes in the screen in the window next to the bed in Individual #1's bedroom. | Screens, windows and doors shall be in good repair. | Changes to be made: The torn screen will be removed and replaced with a new screen to ensure the integrity of the window.Responsible Person: The Maintenance Supervisor will coordinate with Expert Glass Company to replace the screen.Timeline for Change: Expert Glass Company will come to the location, inspect the work and let Avid Care know when they are able to come back and replace the screen. Avid Care will ensure that the screen is replaced no more than 30 days from 7/28/24. To address the issue immediately, Avid Care will place a patch over the torn screen to prevent any insects from coming into the home.Method of Implementation: Once the screen is replaced, Avid Care will ensure the window is in good repair prior to Expert Glass Company leaving the premises. |
08/01/2024
| Implemented |
| 6400.20(b) | The agency has never completed a review and analyzed incidents and conducted and documented a trend analysis. | The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months. | Specific changes made: Avid Care will implement a comprehensive incident review and trend analysis process. This will involve establishing a dedicated Incident Review Committee (IRC).
Who will make the change: The CEO will oversee the implementation of the new process. The Incident Review Committee (IRC) will comprise of the CEO, Executive Director and Program Specialist.
Timeline: Formation of the IRC will be done by 8/1/24. The IRC will develop standardize procedures by 8/20/24. |
08/20/2024
| Implemented |
| 6400.207(5)(I) | At 10:58AM, Individual #1's bed was equipped with partial bedrails on each side. Individual #1's physician wrote an order for a hospital bed on 5/30/2024 because the Individual "requires frequent changes in body position" and 30 degree elevation at the head of the bed. The physician's orders do not specify bed rails. Individual #1's Service Plan, last updated 6/19/2024, does not address the use of bedrails. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Post-surgical or wound care. | Specific changes made: Avid Care will ensure the removal of bedrails from all client beds to comply with 6400.207(5)(I). Responsible person(s): The Executive Director will oversee the removal and replacement process, while the Maintenance Team will execute the physical changes.
Timeline for change: The change was made immediately. |
07/15/2024
| Implemented |