| 6400.144 | Individual #1 is prescribed an 1800 calorie a day diet. From October 2023 to the present, Individual #1 had more than 1800 calories a total of 53 times.
Individual #1 had a pre-op visit on 7/5/24. A Dulcolax Suppository was ordered for "tonight." No suppository was administered. Individual #1 was discharged from hospital after surgery on 7/25/24. The discharge instructions stated that Individual #1 was to alternate taking Acetaminophen (500-1000 mg) and Ibuprofen (600mg) for 3 days. They were to take Tylenol in the morning and at dinner. They were to take Ibuprofen at lunchtime and bedtime. Individual #1 was not administered any Ibuprofen and only received Tylenol. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 9/11/24 The Program Specialist contacted Individual #1's primary care physician to get clarification on the note on a discharge report that stated the following: "Will order Dulcolax suppository now and continue home PO stool softener this evening."
9/12/24 Individual #1's primary doctor responded to the Program Specialist regarding the Dulcolax suppository. Note indicated "Yes, that is an outdated prescription and note." Further clarification indicated "Please disregard the use of Dulcolax. The Individual should resume their normal bowel regiment that has been on for the past year. (Attachment # 2)
9/12/24 the Program Specialist contacted the doctor's office to clarify the discharge summary and prescription instructions of the Tylenol and ibuprofen from discharge summary on 7/25/24. The Program Specialist left a message at the office with the information and asked to have a call back. As of 9/16/24, there has been no callback. (Attachment #3)
9/13/24 SFI Program Specialist took Individual #1 to an appointment with their primary care office. While there, the specialist explained the conflicting information on the discharge instructions from 7/25/24. The discharge instructions and the mar were reviewed. It was indicated on the form "Upon review of both forms, I find the administration of acetaminophen and ibuprofen acceptable and appropriate." (Attachment #4)
9/16/24 a new process was developed by the Director of ID Services to have Program Specialists and nurses review all emergency department and hospital admission discharge instructions to verify all information is correct and accurate. The "Emergency Room/Hospital Admission Discharge Review" form was developed and will be attached to all discharge instructions to confirm information is correct or follow up was completed as necessary.
9/18/24 Program specialists, working managers, and nurses were trained on their responsibilities including health services, such as medical, nursing, pharmaceutical, dental, dietary, and psychological services that are planned or prescribed for the individual shall be arranged for or provided. (Attachment #1)
9/18/24 A training record was signed indicating their attendance and understanding. All program specialists, working managers, and nurses will continue to verify all health services, such as medical, nursing, pharmaceutical, dental, dietary, and psychological services that are planned or prescribed for the individual shall be arranged for or provided. (Attachment #1)
9/19/24 the nurse completed a health assessment with Individual #1. The prescribed 1800 calorie diet was reviewed with Individual #1, including any days that were recorded as exceeding 1800 calories. Training was provided to the individual on the importance of following doctor recommendations and staying within the 1800 calorie daily recommendation. (Attachment #5) |
09/19/2024
| Implemented |
| 6400.145(1) | The Emergency Medical Plans for Individuals #1-3 do not document the hospitals of choice for each individual. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | 9/11/2024 The Emergency removal plan form was updated to include the following information: In the event of an emergency, (Individuals name), will be transported to the individual's preferred hospital/source of healthcare, which is (Name of hospital) or nearest appropriate medical center as applicable.
9/16/24 Emergency Removal plans were updated for Individuals #1-3 to include the preferred hospital/source of health care that will be used in an emergency. (Attachment #7)
9/16/24 The Monthly Supervisory Documentation form was updated to include a monthly review of the emergency medical plan to confirm the individual's preferred hospital/source of health care is documented correctly. (Attachment #8)
9/18/24 Program specialists and working managers were trained on their responsibilities including: The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. (Attachment #1)
9/18/24 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verify all individuals in the home will have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. (Attachment #1) |
09/18/2024
| Implemented |