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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1, diagnosed with Severe ID, Bipolar, Mood Disorder, PTSD, Autism, and Anxiety moved into their current residential home on 2/26/24. They are non-verbal and have a history of self-injurious behaviors, including biting, pinching, hair pulling, and head-banging. Despite having the Behavior Support Plan revised seven times since admission, none of the 24 staff working with them from 2/26/24 to 11/18/24 were trained in their Individual Support Plan, BSP, or dietary protocols.
Since admission, Individual #1 experienced repeated medical issues, including hospitalization from 6/14/24 to 7/7/24 for pneumonia and subsequent dietary adjustments. Following an ear infection on 10/24/24, multiple prescribed medications were delayed or not administered, contributing to ongoing severe pain.
On 10/24/24, Individual #1 was treated for an ear infection at urgent care and later at the ER for severe pain. They were prescribed Gentamicin-Prednisone Ointment, but it was never filled or administered. Persistent ear pain led to another ER visit on 10/27/24 and a PCP appointment on 11/1/24, where they were prescribed lidocaine and benzocaine for pain. However, benzocaine was not administered until 11/4/24, and lidocaine was under-administered until the same date.
On 11/2/24, they returned to the ER for severe pain and were hospitalized from 11/6/24 to 11/15/24. Upon discharge, they remained in pain, with logs showing they banged their head and pulled at their ears until bleeding. On 11/17/24, they pulled at their ears until part of the outer ear was torn off, requiring hospitalization and partial ear amputation. They remain hospitalized as of 12/30/24.
Failures in staff training, medication administration, and timely medical intervention resulted in significant harm. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The staff were retrained on the medication administration process, as well as Individual #1's ISP and BSP. Staff signed an in-person training signature sheet rather than a "read and acknowledge" signature sheet. |
03/31/2025
| Implemented |
| 6400.144 | Individual #1 had a PRN prescription for Milk of Magnesia that was to be administered once daily if no bowel movement in the previous 2 days. This PRN was in place from 2/26/24 -- 8/16/24. Individual #1 had the following times with no bowel movement where no PRN was administered, or the PRN was administered late:
· 3/10/24 PM -- 3/13/24 AM
· 3/22/24 AM -- 3/25/24 AM (PRN was administered at 8:20pm)
· 4/5/24 AM -- 4/8/24 AM (PRN was administered on 4/8)
· 6/4/24 AM -- 6/7/24 AM
· 7/13/24 AM -- 7/16/24 AM (PRN was administered on 7/16/24)
· 8/3/24 AM -- 8/6/24 AM (PRN was administered on 8/6/24)
· 8/9/24 AM -- 8/13/24 AM (PRN was administered on 8/12/24 and again on 8/13/24)
On 8/16/24, Individual #1's bowel protocol was changed by the doctor. After 2 days of no bowel movement, Individual #1 was to be administered Miralax. If no bowel movement for 6 hours, another dose of Miralax was to be given. If no bowel movement continued into the 3rd day, Miralax and Milk of Magnesia were to be administered. If no bowel movement 6 hours after this PRN administration, the PCP was to be contacted.
· From 10/12/24 AM to 10/15/24 AM, there were no documented bowel movements. Miralax was not given until 10/15/24.
· From 10/26/24 AM to 10/29/24 AM there were no documented bowel movements and no PRN medication was given. | 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.
| On 1/7/25, staff was retrained on bowel protocol when to give Miralax (at the end of the second day). |
03/31/2025
| Implemented |
| 6400.32(c) | Between the dates of 6/3/24 and 6/5/24, multiple staff noted an increase in self-injurious behaviors, including banging head multiple times, pulling hair, biting, and pinching. No redirections worked; however, no medical attention was sought for Individual #1 until after 9pm on 6/5/24.
On 6/9/24, staff observed a bruise on Individual #1's jawline, which worsened to a black eye and swelling by 6/10/24. Despite administering pain relief and recommending soft foods, no medical attention was sought until 6/12/24.
On 7/7/24, Individual #1 was released from the hospital, where they were treated for pneumonia, at around 11:40am. At 11:30pm, Staff Person #5 noted Individual #1's rapid breathing and unsteadiness, measuring a pulse oximeter reading at 87%. They consulted Staff Person #7, a non-medical professional, who advised waiting an hour. At 12:40am, the pulse ox remained at 87%, but no medical help was sought, despite guidelines recommending emergency care for levels below 88%.
At a 7/9/24 follow-up, Individual #1's PCP ordered pulse-ox checks for shortness of breath and repositioning for levels below 90%. Medical attention was to be sought if levels remained low for an hour. They were also instructed to use an incentive spirometer until 7/20/24. However, the pulse-ox protocol was not implemented until 7/15/24, and the spirometer was never used.
Individual #1 was released from the hospital on 7/7/24 with an order to hold all vitamins and supplements for 3 to 5 days. These medications were held until 7/24/24 without a doctor's order extending the hold.
On 7/23/24 and 7/25/24, it was noted that Individual #1 had yellow, cloudy, and foul-smelling urine. On 7/26/24, Individual #1 was up frequently overnight using the restroom and was unsteady on their feet. No medical attention was sought for these symptoms.
On 8/16/24, Individual #1 had a PCP appointment for pain, a bowel protocol follow-up, and a crack, swelling, and a rash on their lower lip. The PCP indicated the individual's lip likely had a yeast/fungal infection and prescribed Clotrimazole cream to be applied to the lip twice daily until the area cleared. This medication was not administered to Individual #1 until 8/26/24, and then was only administered twice. At this same appointment, Individual #1 was prescribed a daily Senna. This medication was not administered to Individual #1 for the first time until 8/23/24.
The failure to administer medications timely and seek medical attention promptly created conditions conducive to serious harm for Individual #1. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | -On 1/16/25, Individual #1's BSP was updated to state the following: 'If [Individual #1] shows any signs of harm to the head, such as bruising, excessive redness, lumps starting to form, Team Members need to call 911.Staff were trained on the updated BSP. |
02/15/2025
| Implemented |
| 6400.165(c) | Individual #1 has a PRN Acetaminophen prescription that can be administered 2 tablets every 4 hours for pain with a maximum of 4 doses per 24 hours. On the following dates these instructions were not followed:
· 4/12/24 -- administered at 4pm and 7pm
· 4/14/24 -- administered at 8am and 11am
· 4/22/24 -- administered at 12:30pm and 4pm
· 5/1/24 -- administered at 1:30pm and 5pm
· 6/3/24 -- administered at 1:30pm and 5pm
· 6/4/24 -- administered at 1:30pm and 5pm
· 6/13/24 -- administered at 3pm and 5:45pm
· 8/3/24 -- administered at 1:40pm and 5pm
· 10/10/24 -- administered at 8:17 and 11:15
Individual #1 had a PRN ibuprofen prescription that was to be administered 1 tablet every 6 hours for pain. On the following dates these instructions were not followed:
· 5/14/24 -- administered at 6:26am, 12pm, and 455pm | A prescription medication shall be administered as prescribed. | On 1/7/25, staff was retrained on how to ensure that PRN administrations are spaced far enough apart. |
03/31/2025
| Implemented |
| 6400.166(a)(10) | Individual #1 has been frequently administered PRN medications from their 2/26/24 date of admission until their 11/17/24 hospitalization. Most of the time, the times that these medications are administered are illegible, not present, or do not include AM or PM so it is unclear when the medication was administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Staff will be retrained on writing times that PRNs were given legibly on paper MAR. |
05/31/2025
| Implemented |
| 6400.167(a)(1) | Individual #1 should have been administered their PRN Milk of Magnesia on the following dates, but it was not administered: 3/12/24, 3/24/24, 4/7/24, 6/6/24, 7/15/24, 7/22/24, 8/5/24, 8/11/24. Individual #1 should have been administered their PRN Miralax on the following dates, but it was not administered: 10/14/24 and 10/28/24.
Individual #1 was released from the hospital on 7/7/24 with an order to hold all vitamins and supplements for 3 to 5 days. These medications included Vitamin D2, Evening Primrose, Multivitamin, Vitamin E, Flaxseed Oil, and Vitamin B Complex. These medications were not administered until 7/24/24.
On 8/16/24, Individual #1 had a PCP appointment for pain, a bowel protocol follow-up, and a crack, swelling, and a rash on their lower lip. The PCP indicated the individual's lip likely had a yeast/fungal infection and prescribed Clotrimazole cream to be applied to the lip twice daily until the area cleared. This medication was not administered to Individual #1 until 8/26/24, and then was only administered twice. At this same appointment, Individual #1 was prescribed a daily Senna. This medication was not administered to Individual #1 for the first time until 8/23/24.
On 11/1/24, Individual #1 was prescribed Lidocaine to be administered every hour as needed for pain between 7am and 7pm and Benzocaine to be administered every 3 hours as needed for pain from 7pm to 7am. Individual #1 continually expressed pain. The only times that Lidocaine was administered on 11/1/24 through 11/4/24 were at 7am and 3pm. The additional administrations did not occur until 11/4/24. The Benzocaine was not administered at all until 11/4/24. | Medication errors include the following: Failure to administer a medication. | -On 1/7/25, staff were retrained on when and how to give PRN medications.
-On 1/17/25, Nursing Services Coordinator trained Nursing Consultant and Residential Manager overseeing Individual #1's home on oversight and catching med errors faster. A plan was made for the Nurse and Manager to meet regularly, improve medication training practices, and check the MARs and BM charts regularly. |
04/30/2025
| Implemented |
| 6400.167(a)(3) | On 10/31/24, Individual #1's dose of Valproic Acid was changed from 20ml in the morning and 15ml in the evening to 20 ml in the morning and 10ml in the evening. This change was not made until 11/15/24 in the home. Individual #1 received the incorrect dose of Valproic Acid in the evening from 11/1/24 through 11/5/24. The individual was hospitalized from 11/6/24 through 11/15/24. | Medication errors include the following: Administration of the wrong dose of medication. | -A Certified Investigation was initiated to investigate this incident. An Admin Review will review the CI Report, make a determination, and create corrective actions to address this issue and reduce the likelihood of reoccurrence. |
02/15/2025
| Implemented |
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