|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 had a diagnosis of Severe IDD, Nocturnal Hypoxia, Specific Antibody Deficiency, Down Syndrome, Autism, Mood Disorder, Bipolar, Dysphagia and Grave's Disease. Individual #1 required partial physical assistance with all ADL's, including bathing and toileting. Individual #1 was non-verbal.
Individual #1 was hospitalized from 2/6/25 through 3/13/25 with acute hypoxemic respiratory failure due to Influenza A and superimposed bacterial infection. During this hospitalization, Individual #1 was intubated. The individual was also diagnosed with Nocturnal Hypoxia, requiring ongoing oxygen treatment while sleeping, and Specific Antibody Deficiency, which did not allow for Individual #1 to produce specific antibodies to fight off infection. Individual #1's dysphagia diagnosis also led to a change in diet to thin liquids, and regular diet with soft foods cut into bite sized pieces and made moist with sauce and gravies. Due to low oxygen levels, Individual #1 returned to the hospital on 3/13/25 and remained hospitalized until 3/18/25.
Individual #1 had multiple doctor's appointments for wheezing and coughing, and a pulmonologist appointment was made for 5/23/25. At this appointment, Individual #1 was prescribed nectar-thick liquids to reduce aspiration.
As described in the Licensing Inspection Summary below, there were multiple factors that created an unsafe environment for Individual #1. Of the 32 staff who worked in the individual's home between 3/13/25 and 8/28/25, none of them were fully trained in Individual #1's plans, protocols, and medical care needs. There were multiple staff who were not trained in administering medications via nebulizer who administered this medication to the individual. Only one member of staff was trained on how to properly administer Individual #1's required night-time oxygen treatment.
Due to Individual #1's history of aspiration pneumonia and history of getting very ill very quickly, there were protocols in place to ensure Individual #1's health. Individual #1 had a Nocturnal Hypoxia/Specific Antibody Deficiency protocol that indicated that their temperature was to be taken twice daily and recorded. If the individual's temperature was 100.4 degrees or above, the PCP or Urgent Care was to be contacted for an appointment. If the individual's temperature was 102.5 or above, 911 was to be called. There was tracking available for this protocol, however, on many dates between 3/13/25 and 8/28/25, either the temperature was marked as "completed," but no result was recorded, or the temperature was only taken once daily. This inconsistency does not allow for confirmation that the protocol was being followed accurately or to ensure Individual #1 was receiving medical attention timely.
Individual #1's Shortness of Breath/Signs of Illness protocol indicates that Individual #1's pulse ox level was to be taken if Individual #1 exhibited the following symptoms: difficulty breathing, decreased alertness, confusion, extreme drowsiness, wheezing, noisy or labored breathing, appearing [they] can't catch breath, skin paler than usual, and mouth or fingertips turning blue. If Individual #1's oxygen level was below 90%, the individual was to be repositioned and checked in an hour. If it remained under 90%, 911 was to be called. If Individual #1's oxygen was under 85%, 911 was to be called immediately. There were 12 occasions between 3/13/25 and 8/10/25 in Individual #1's daily logs that "coughing," "gagging," and "tiredness" were noted, but the protocol was not followed, and no medical attention was sought.
On 8/14/25, Individual #1 was taken to their PCP for an increase in tiredness and agitation. They were prescribed Augmentin and additional nebulizer treatments due to an upper respiratory infection. On 8/18/25, it was noted that Individual was increasingly wheezing and coughing, so they were taken to Urgent Care, where an x-ray was completed. No results were given before Individual #1 was sent home and told to continue medications prescribed on 8/14/25. Individual #1 continually worsened throughout the shift, and was taken to the ER on 8/18/25, where they were hospitalized until 8/22/25. Upon discharge, Individual #1 was diagnosed with pneumonia and referred for hospice care. Their diet was changed back to thin liquids.
Individual #1 continued to decline over the next couple of days, showing increased agitation and behaviors. On 8/25/25, Individual #1 returned to the hospital, where they passed away on 8/28/25. Individual #1's death certificate lists a primary cause of death as chronic respiratory failure with aspiration and dysphagia also listed as causes.
Failure to ensure staff were properly trained, failure to ensure medical care was sought timely, and failure to ensure protocols were followed created conditions conducive to serious harm for Individual #1. | 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. | All staff involved in the care of individuals will be retrained on individual specific health protocols, emergency response procedures including when to call 911, when to contact the PCP, and proper oxygen use. Nursing staff will review all individual's current health plans to ensure accuracy, and completeness. A licensed nurse will verify that all adaptive equipment is functioning properly and documented use appropriately. |
11/10/2025
| Accepted |
| 6400.141(c)(4) | Individual #1 had not had a vision examination since 3/27/24. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Nursing Services Coordinator will retrain the Nursing Team on reviewing Annual Physical paperwork following an Annual Physical. Target date: 11/30/25. |
12/31/2025
| Accepted |
| 6400.144 | Individual #1's daily logs noted that the individual had an unwitnessed fall in the kitchen on 7/18/25. Medical attention was not sought for Individual #1 to ensure that injury did not occur.
Individual #1 had a Nocturnal Hypoxia/SAD protocol that indicated that her temperature was to be taken twice daily and recorded. If the individual's temperature was 100.4 degrees or above, the PCP or Urgent Care was to be contacted for an appointment. If the individual's temperature was 102.5 or above, 911 was to be called. There is tracking available for this protocol, however, on many dates between 3/12/25 and 8/28/25, either the temperature was marked as "completed," but no result was recorded, or the temperature was only taken once daily. This inconsistency does not allow for confirmation that the protocol was being followed accurately.
As part of Individual #1's Shortness of Breath/Signs of Illness protocol, Individual #1's pulse ox level was to be taken if Individual #1 exhibited the following symptoms: difficulty breathing, decreased alertness, confusion, extreme drowsiness, wheezing, noisy or labored breathing, appearing [they] can't catch breath, skin paler than usual, mouth or fingertips turning blue. If Individual #1's oxygen level was below 90%, the individual was to be repositioned and checked in an hour. If it remained under 90%, 911 was to be called. If Individual #1's oxygen was under 85%, 911 was to be called. This protocol was not followed on the dates below:
· 3/30/25 -- The individual woke up, coughed and gagged 10 times before going back to sleep.
· 4/20/25 -- "Rattley" cough
· 4/27/25 -- tired, increased agitation
· 4/29/25 -- coughing frequently overnight
· 4/30/25 -- coughing frequently overnight, gagged several times until the individual "puked"
· 6/3/25 -- phlemy cough overnight, tired, not eating much
· 6/4/25 -- phlemy cough overnight, gagging
· 6/30/25 -- coughing/moaning/groaning while sleeping
· 7/18/25 -- wet cough
· 7/25/25 -- coughing throughout the day
· 8/9/25 -- congestion, continually clearing throat
· 8/10/25 - gagging | 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.
| DPOC created 11/12/25 by JC All staff involved in the care of individuals will be retrained on individual specific health protocols, emergency response procedures including when to call 911, when to contact the PCP, and proper oxygen use. Nursing staff will review all individual's current health plans to ensure accuracy, and completeness. A licensed nurse will verify that all adaptive equipment is functioning properly and documented use appropriately. |
12/12/2025
| Accepted |
| 6400.18(b)(2) | The medication errors described in 6400.167a4 were not reported in the department's incident management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | 3 Medication Error Reports will be entered into EIM by the Residential Coordinator, one for each instance where the medication was administered outside of the prescribed timeframe. Target date: 10/30/25. |
11/15/2025
| Accepted |
| 6400.32(d) | Individual #1 required partial physical assistance with all ADL's, which includes bathing and showering. Between 3/12/25 and 8/28/25, Individual #1 was only assisted with showering on 19 days. The individual was also bathed with wipes one time during this time period and given a "bird bath" one time during this time period. Multiple times, staff noted that Individual #1 smelled of body odor due to the lack of bathing. Additionally, Individual #1 had ongoing rashes on their buttocks, under their breasts, and on their inner thigh area that were frequently painful. The failure to assist Individual #1 in consistently showering and bathing is undignified and disrespectful. | An individual shall be treated with dignity and respect. | All staff assigned to provide direct care will be retrained on any ADL support plans and hygiene schedules for the individuals they care for.
·A licensed nurse will assess skin integrity, and a treatment plan will be implemented for any individual with existing rashes and skin irritation.
· A consistent daily bathing schedule will be created for each individual requiring assistance with bathing, identifying the responsible staff for each shift.
· The Program Supervisor will verify completion of bathing assistance through daily hygiene checklists, with documentation signed by both the assisting staff and the on-duty supervisor.
· |
12/12/2025
| Accepted |
| 6400.52(c)(6) | Individual #1 was hospitalized from 2/6/25 -- 3/12/25. Upon discharge, Individual #1 had multiple care plans put into place that staff were to be trained on. These plans and protocols were updated frequently, which required new staff training. These plans are as follows:
· Individual Support Plan (ISP)
· Behavior Support Plan (BSP)
· Ear Wound Care -- updated 3/12/25, 5/20/25, and 7/1/25
· Eating Recommendations -- updated 3/12/25, 5/23/25, and 8/22/25
· Blood Pressure/Heart Rate protocol
· Nocturnal Hypoxia protocol
· SAD protocol
· Blood Pressure and Pulse Ox protocol
· Shortness of Breath/Signs of Illness protocol
· Use of Oxygen
There were 32 people who worked in Individual #1's home from 3/12/25 through 8/28/25. None of these staff were completely trained to work with Individual #1.
· Staff persons #3, 4, 5, 7, 12, 20, 21, 22, 23, 24, and 26 weren't trained in any of Individual #1's plans and protocols.
· Staff persons #1, 2, 19, 25, 27, 28, 29, 31 and 32 were only trained in Individual #1's BSP.
· Staff person # 17 was only trained in Individual #1's 3/12/25 Ear Wound Care, 3/12/25 Eating Recommendations, Nocturnal Hypoxia, SAD, BP/Pulse Ox, Shortness of Breath/Signs of Illness, and Use of Oxygen protocols.
· Staff person #6 was only trained in BP/Pulse Ox and BSP.
· Staff person #8 was only trained in 3/12/25 Ear Wound Care, 3/12/25 Eating Recommendations, Nocturnal Hypoxia, SAD, BP/Pulse Ox, Shortness of Breath/Signs of Illness, and BSP.
· Staff persons #9, #11, #13, #14, and #15 were only trained in BP/Pulse Ox, Shortness of Breath/Signs of Illness, and BSP.
· Staff person #10 was only trained in Nocturnal Hypoxia, SAD, BP/Pulse Ox, Shortness of Breath/Signs of Illness, and BSP.
· Staff person #16 was only trained in BP/Pulse Ox and Shortness of Breath/Signs of Illness.
· Staff person #18 was only trained in 3/12/25 Ear Wound Care, 3/12/25 Eating Recommendations, Nocturnal Hypoxia, SAD, BP/Pulse Ox, and Shortness of Breath/Signs of Illness.
· Staff person #30 was only trained in 3/12/25 Ear Wound Care, 3/12/25 Eating Recommendations, Nocturnal Hypoxia, SAD, BP/Pulse Ox, Shortness of Breath/Signs of Illness, Use of Oxygen, and BSP. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | DPOC created 11/12/25 by JC
The Program Nurse and Program Director will conduct a full review of Individual's medical, behavioral, and health protocols.
·Comprehensive retraining sessions will be held for all assigned staff on Individual's updated plans, including all protocols.
Competency assessments will be completed by the nurse to verify understanding and skill proficiency.
·Only staff who successfully completed all training components and demonstrated competency will be permitted to provide care to individuals. |
11/12/2025
| Accepted |
| 6400.162(b)(2)(vi) | Staff person #24 is not trained to administer medications via nebulizer. This staff person has administered medications to Individual #1 via nebulizer. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Medications, injections, procedures and treatments as permitted by applicable statutes and regulations. | DPOC created 11/12/25 by JC Staff Person #24 was immediately removed from performing any medication administration duties, including nebulizer treatments.
·The Program Nurse provided retraining to staff on the medication administration policy, emphasizing that only trained and certified personnel may administer any medication, including nebulized treatments.
· Staff Person #24 will not resume medication administration duties until successfully completing ODP-approved Medication Administration Training and demonstrating competency through return demonstration. |
12/12/2025
| Accepted |
| 6400.165(c) | Individual #1's physician changed their ear wound care instructions from medihoney once daily to using triple antibiotic twice daily with dressing changes on 4/3/25. The home did not implement this medication and protocol change until 4/7/25. | A prescription medication shall be administered as prescribed. | DPOC created 11/12/25 by JC All staff involved in the care of individuals will be retrained on individual specific health protocols, emergency response procedures including when to call 911, when to contact the PCP, and proper oxygen use. Nursing staff will review all individual's current health plans to ensure accuracy, and completeness. A licensed nurse will verify that all adaptive equipment is functioning properly and documented use appropriately. |
12/12/2025
| Accepted |
| 6400.165(e) | Individual #1's physician did not discontinue Petroleum Jelly until 3/21/25. The home discontinued this medication on 3/18/25. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | DPOC created 11/12/25 by JC
·All staff involved were counseled on the requirement that only licensed medical professionals or prescribers may discontinue medications, including topical treatments. |
12/12/2025
| Accepted |
| 6400.167(a)(4) | Individual #1 was to be administered their morning dose of Clotrimazole between 6am and 10am. On 4/10/25, this medication was administered at 11:18am. On 4/25/25, this medication was administered at 11:54am. On 5/2/25, this medication was administered at 11:55am. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | 3 Medication Error Reports will be entered into EIM by the Residential Coordinator, one for each instance where the medication was administered outside of the prescribed timeframe. Target date: 10/30/25. |
11/15/2025
| Accepted |
| 6400.196(a) | Individual #1 had a restrictive Behavior Support Plan that included a physical restraint component. Staff persons #1, 2, 3, 4, 5, 11, 19, 22, 25, 26, 27, 28, 29, 31, and 32 were not trained in the use of a physical restraint. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | DPOC created on 11/12/25 by JC
All staff (#1--#32) who support Individual #1 were removed from restraint implementation duties until they successfully completed certified crisis management and restraint training. |
12/12/2025
| Accepted |
| 6400.196(b) | Individual #1 had a restrictive BSP that included a physical restraint component. Staff persons #1, 2, 3, 4, 5, 11, 19, 22, 25, 26, 27, 28, 29, 31, and 32 have not experienced the use of a physical restraint. | If a physical restraint will be used, the staff person who implements or manages the behavior support component of the individual plan shall have experienced the use of the physical restraint directly on the staff person. | DPOC created 11/12/25 by JC All staff (#1--#32) who support Individual #1 were removed from restraint implementation duties until they successfully completed certified crisis management and restraint training, including having the restraint used on them. |
12/12/2025
| Accepted |
|
|
|
| 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 |
|
|