Brightside Homes III

The facility failed to ensure that an appropriate licensed health professional participates in the on-site review and evaluation of residents' health status, care plans, and care provided for residents requiring specific personal care tasks. This includes oversight for tasks such as wound care, catheter management, and medication administration via feeding tubes.

The facility failed to ensure physician orders were properly implemented for a resident. Specifically, the facility did not administer divalproex ER twice daily as ordered by the physician, instead administering it only once daily per the medication administration record. This discrepancy was noted during a review of the resident's orders, medication records, and an interview with the caregiver.

The facility failed to ensure physician orders were properly implemented for a resident. Specifically, a physician's order for divalproex ER to be administered twice daily was not transcribed correctly onto the Medication Administration Record (MAR), resulting in the medication being administered only once daily. Additionally, there was no documentation of administration for potassium chloride (KCl) ER, and the medication was not available for use.

The facility failed to ensure physician orders were implemented for a resident by continuing to administer a medication that had been ordered to be discontinued. Specifically, clindamycin benzoyl peroxide was administered daily from July 2022 through December 2022 despite a discontinuation order dated 07/08/22. The Administrator was unaware of the discontinued order and had not notified the pharmacy or removed the medication from the resident's basket.

The facility failed to ensure physician orders were implemented for one resident. Specifically, a physician's order to discontinue clindamycin benzoyl peroxide, dated 07/06/22, was not followed, as the medication continued to be administered daily through December 2022. The pharmacy was also not notified of the discontinued order.

The facility failed to notify the Division of Health Service Regulation that the evacuation capabilities of three residents had changed. These residents had cognitive or physical impairments that prevented them from evacuating the facility independently, which contradicted the facility's license stating all residents were ambulatory.

The facility failed to ensure that one of three staff members (Staff C) had been competency validated by a licensed health professional for personal care tasks. Specifically, there was no documentation of validation for tasks such as assistance with ambulation and managing continuous oxygen and inhalation medication. Record review and interviews confirmed the staff member was performing these tasks without required competency verification.