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Source: NC Division of Health Service Regulation
The facility failed to administer medications as ordered for 2 of 3 sampled residents. Specifically, for Resident #1, there was no documentation that the ordered 81mg aspirin was administered between 06/12/24 and 06/17/24.
The facility failed to administer medications as ordered for 2 of 3 sampled residents. Specifically, for Resident #1, there was no documentation of aspirin administration from 06/12/24 to 06/17/24, despite the medication being present on hand. The Supervisor-in-Charge admitted to administering the medication but failing to document it on the Medication Administration Record (MAR).
The facility failed to ensure referral and follow-up to meet the routine health care needs of residents. Specifically, the facility failed to schedule or document appointments for two residents, including a dermatologist referral for Resident #1 and a gastroenterologist referral for Resident #3.
The facility failed to ensure necessary referral and follow-up care for residents to meet their routine health care needs. Specifically, the facility did not document or complete scheduled appointments for a dermatologist and a gastroenterologist for two sampled residents.
The facility failed to ensure necessary medical referrals and follow-up care were coordinated for residents. Specifically, the facility did not schedule a podiatry referral for Resident #3 and failed to provide necessary podiatry care for Resident #1, who presented with significant toenail overgrowth and swelling.
The facility failed to ensure necessary follow-up care and referrals for residents' routine healthcare needs. Specifically, the facility did not schedule a podiatry appointment for a resident despite a referral from their primary care provider, and a medication aide had not yet been trained to manage physician appointments.
The facility failed to ensure that one of two sampled staff members was tested for tuberculosis disease upon hire. Specifically, there was no documentation of an initial TB skin test or a second skin test for the employee, and the employee's hire date was not listed in the personnel record.
The facility failed to ensure proper staff qualifications for Staff A. There was no documented hire date and no evidence of a completed statewide criminal background check or a signed consent form for a background check.
The facility failed to maintain documentation for Staff A (SIC/MA) regarding required tuberculosis testing. Specifically, there was no record of an initial TB skin test being placed or read, nor was there documentation of a second skin test.
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