Bethamy Retirement Center

The facility failed to ensure that 10 of 10 exit doors had engaged and audible alarms to prevent disoriented residents from exiting without staff knowledge. Specifically, an exit door separating the North and South Halls was found with its alarm switch in the off position, allowing residents, staff, and visitors to pass through without an audible alert.

The facility failed to ensure that 10 of 10 exit doors had engaged and audible alarms to prevent disoriented residents from exiting without staff knowledge. Specifically, an exit door alarm was found in the 'off' position, and staff failed to respond to the alarm when it was activated during the survey.

The facility failed to ensure that 10 of 10 exit doors had engaged audible alarms to alert staff when residents who are disoriented or exhibit wandering behavior exit the building. This failure was evidenced by residents being found outside the facility without staff knowledge or supervision.

The facility failed to ensure that medication orders and treatments were verified for accuracy and completeness. Specifically, a physician's order for clonazepam 0.5mg twice daily was not properly verified against the eMAR, resulting in the administration of an incorrect dose (1mg) based on an unverified pharmacy entry. Medication aides failed to check the pharmacy-entered eMAR orders against the actual signed physician orders in the resident's record.

The facility failed to contact the resident's physician to clarify medication orders for one resident. Specifically, the resident's records showed a discrepancy where the dosage for clonazepam changed from 1mg twice daily to 0.5mg twice daily without a corresponding physician's order available for review.

The facility failed to respond immediately to a resident experiencing difficulty breathing and chest pain. Staff waited between 30 to 40 minutes to contact EMS because they were attempting to communicate among staff and follow a procedure requiring supervisor approval before calling 911.

The facility failed to respond immediately to a resident experiencing difficulty breathing and chest pain. Staff waited between 30-40 minutes to contact EMS because they were attempting to contact a supervisor for permission to send the resident out, resulting in the resident requiring CPR in the ambulance.