Positive Lifestyles #2

The facility failed to ensure that all staff members had a state-wide criminal background check in their personnel files. Specifically, a review of Staff B's record showed a county background check was completed, but no documentation of a state-wide check was present.

The facility failed to ensure that therapeutic diets, specifically low carbohydrate/sugar (LCS) diets, were served as ordered by the physician. Resident #1 was observed being served breakfast items, including two toaster pastries, that contained high amounts of sugar and carbohydrates inconsistent with the prescribed diet.

The facility failed to ensure that one of two sampled staff members had a state-wide criminal background check completed upon hire. While a county-level check was documented, there was no evidence of the required state-wide background check in the employee's personnel record.

The facility failed to ensure that one sampled resident received a low concentrated sweets (LCS) diet as ordered. A review of the resident's medical records showed no diet order was documented on the FL-2, despite a diagnosis of diabetes mellitus Type II.

The facility failed to provide adequate supervision for a resident with dementia, psychosis, and altered mental status. This lack of oversight resulted in the resident eloping from the facility and spending 18 hours in freezing temperatures in the woods, leading to hypothermia and hospitalization.

The facility failed to provide adequate supervision for a resident with dementia, altered mental status, and psychosis. This lack of supervision resulted in the resident eloping from the facility and spending 18 hours in freezing temperatures, leading to hypothermia.