Spring Arbor of Wilmington

The facility failed to ensure medications were administered as ordered for a resident requiring antibiotic treatment for a neck infection. Although hospital discharge orders for Augmentin were provided, the medication was not started as prescribed, and the resident did not receive the treatment as intended.

The facility failed to ensure medications were administered as ordered for one resident. Specifically, an antibiotic (Augmentin) ordered upon hospital discharge on 06/18/24 was not started until 06/22/24 because the medication order was not processed timely. This resulted in a delay in treatment for a diagnosed neck infection.

The facility failed to ensure medications were administered according to physician orders and safety protocols. Specifically, staff crushed an extended-release (ER) medication (metoprolol succinate) that was explicitly labeled 'DO NOT CRUSH,' which can lead to dangerous medication dosing errors.

The facility failed to ensure medications were administered as ordered for several residents. Specifically, staff crushed a metoprolol succinate ER tablet, which is a time-released medication, and mixed it with coffee, and errors were noted regarding antacid and cancer medication administration.

The facility failed to provide sufficient preparation and orientation to ensure a safe and orderly discharge. This includes failure to properly notify necessary parties and provide required documentation to caregivers during the discharge process.

The facility failed to assure proper referral and follow-up to meet the routine and acute health care needs of residents. Specifically, a resident experienced a delayed referral to a specialist (Urologist).

The facility failed to provide supervision in accordance with residents' assessed needs, care plans, and current symptoms. This resulted in a physical altercation involving a resident with a history of aggressive behavior that led to severe injuries and death, as well as multiple falls for other residents requiring emergency room visits.

The facility failed to implement a physician's order for one resident regarding the application and removal of thromboembolic deterrent (TED) hose as needed for swelling. Observations and medication records showed the resident was not wearing the required hose and there was no documentation of the order being followed for the months of January, February, and March 2020.