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Source: NC Division of Health Service Regulation
The facility failed to ensure that one of three sampled residents had completed required tuberculosis testing upon admission. Specifically, Resident #3 had a documented negative TB skin test from 2020, but no subsequent testing was available in the resident record or at the local health department.
The facility failed to ensure that one of three sampled residents had completed the required tuberculosis (TB) testing upon admission. Specifically, documentation only showed a single TB skin test for Resident #3, whereas the facility's protocol and regulations require a completed series of testing. The Administrator acknowledged overlooking the lack of available documentation from the resident's previous facility.
The facility failed to ensure medication administration records (MAR) were accurate for one resident. Specifically, an active order for oxycodone/APAP existed on the MAR, but the medication was not available in the facility and had not been dispensed by the pharmacy since July 2020. The facility failed to obtain a discontinuation order or follow up on the discrepancy for approximately one year.
The facility failed to ensure medication administration records were accurate for one resident. Specifically, there was no documentation of the administration of oxycodone/APAP as prescribed, and an observation revealed the medication was not available for administration.
The facility failed to ensure that Medication Administration Records (MARs) were accurate and included the initials of the Medication Aide responsible for administration. Specifically, for 2 of 2 sampled residents, the records lacked the required documentation of the staff member who administered the medication.
The facility failed to ensure that Medication Administration Records (MARs) accurately included the initials of the Medication Aide who administered the medication. Specifically, for two sampled residents, the records only documented the initials of the Administrator rather than the person actually administering the medication.
The facility failed to ensure that Medication Administration Records (MARs) were accurate and included the initials of the Medication Aide responsible for administration. Specifically, for 2 of 2 sampled residents, the records lacked the required identification of the staff member who administered the medication.
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