Mercy's Care Home I

Based on documentation review, record review, and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training in fall prevention and fall recovery. The deficient practice posed a risk to the health and safety of residents if employee's were not able to prevent or recover residents in the event of a fall. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Falls Prevention and Fall Recovery Training Policy and Procedure." However, the policy did not include a developed program that covered initial training and the frequency of the continued competency training. 2. A review of E1's (hire date 2017) personnel record revealed documentation to include annual training in fall prevention and recovery was not available for review. 3. A review of E2's (hired in 2020) personnel record revealed documentation to include annual training in fall prevention and recovery was not available for review. 4. In an interview, E1 acknowledged the facility's fall prevention and fall recovery training program did not include initial training and the frequency of the continued competency training in the fall prevention and fall recovery. E1 acknowledged E1's, and E2's personnel records were missing their annual training documentation.

Based on record review, observation, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. A review of R1's medical record revealed a current service plan. The service plan revealed R1 received medication administration. 2. A review of R1's medication administration record (MAR) indicated R1 received "Pantoprazole 40 mg 1 tab PO QD, at 7 AM" between June 14, 2023 to June 28, 2023. Between June 29, 2023 to June 30, 2023 Pantoprazole was documented as not being administered because the medication was"discontinued". 3. A review of R1's medical record revealed an undated medication order signed by a medical practioner. The medication order listed "Pantoprazole 40 MG, 1 TAB oral daily before breakfast". However, an order indicating the medication was discontinued was not available for review in R1's medical record. 4. In an interview, E1 reported E2 accidentally marked the medication was discontinued. E1 stated R1 "ran out of the medication". E1 reported E2 should have documented that the medication "ran out". E1 reported having difficulties ensuring compliance with the medication being administered as scheduled because E1 reported R1 handled the re-order of R1's medications.