Summit Place of Southpark

The facility failed to ensure a resident had a physician's order to self-administer acetaminophen and triple antibiotic ointment. Additionally, an unlabeled bottle of acetaminophen was observed at the resident's bedside without proper documentation in the resident's record or medication administration record.

The facility failed to implement its policy for an attempted elopement for a resident with severe dementia and wandering history, resulting in the resident hopping over a security gate. Specifically, door alarms were non-functional, and the facility failed to update the resident's individualized service plan with necessary interventions to minimize elopement risk.

The facility failed to provide adequate supervision and implement elopement policies for a resident with a known history of wandering and agitation. Specifically, an alarm system on the Special Care Unit doors was non-functional, and the facility failed to complete a required Elopement Risk Evaluation, which resulted in the resident eloping by climbing a security gate.

The facility failed to ensure medications were administered as ordered, resulting in a 14% medication error rate during an 8:00am medication pass. Specifically, a resident received only one Senna tablet instead of the prescribed two tablets, and errors were noted involving a topical pain patch, a calcium supplement, an antipsychotic, a cholesterol medication, and two vitamin supplements.

The facility failed to ensure medications were administered as ordered for several residents. Specifically, a medication aide administered only one Senna tablet instead of the prescribed two tablets for Resident #6, and errors were noted involving a topical patch, a calcium supplement, an antipsychotic, and cholesterol medication.

The facility failed to properly manage and implement pharmacy recommendations. There was a lack of consistent processes for ensuring new physician orders and pharmacy recommendations were appropriately tracked, communicated to providers, and documented in resident records.

The facility failed to ensure that Resident #5 had a physician's order to self-administer acetaminophen and triple antibiotic ointment. Additionally, the resident's medications were found unlabeled with resident identifiers, and the resident had not undergone a required self-administration assessment.

The facility failed to serve therapeutic diets as ordered by the resident's physician. Specifically, Resident #3, who required nectar-thickened liquids due to dysphagia, was served thin water and thin liquid soup. Staff failed to reference the diet list and did not communicate the need for thickened soup to the kitchen.

The facility failed to serve therapeutic diets as ordered by the resident's physician. Specifically, one resident with an order for nectar-thickened liquids was served thin water during lunch service. The staff member responsible admitted to serving the incorrect consistency because they had not referenced the diet list and were unaware of the recent change in the resident's diet order.