State of Michigan DEPARTMENT OF HUMAN SERVICES

Transcription

1 RICK SNYDER GOVERNOR State of Michigan DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING MAURA D. CORRIGAN DIRECTOR August 13, 2012 Julie Norman Farmington Hills Inn W. Twelve Mile Road Farmington Hills, MI RE: License #: Investigation #: AH A Farmington Hills Inn Dear Ms. Norman: Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following: How compliance with each rule will be achieved. Who is directly responsible for implementing the corrective action for each violation. Specific time frames for each violation as to when the correction will be completed or implemented. How continuing compliance will be maintained once compliance is achieved. The signature of the responsible party and a date. If you desire technical assistance in addressing these issues, please feel free to contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action. P.O. BOX LANSING, MICHIGAN (517)

2 Please review the enclosed documentation for accuracy and feel free to contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please feel free to contact the local office at (248) Sincerely, Loma M Campbell, Licensing Staff Bureau of Children and Adult Licensing Suite N. Saginaw Pontiac, MI (248) enclosure P.O. BOX LANSING, MICHIGAN (517)

3 MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: AH A Complaint Receipt Date: 07/02/2012 Investigation Initiation Date: 07/03/2012 Report Due Date: 08/01/2012 Licensee Name: Licensee Address: Alycekay Co W 12 Mile Rd. Farmington Hills, MI Licensee Telephone #: (810) Administrator: Authorized Representative: Name of Facility: Facility Address: Julie Norman Julie Norman Farmington Hills Inn W. Twelve Mile Road Farmington Hills, MI Facility Telephone #: (248) Original Issuance Date: 12/29/2000 License Status: REGULAR Effective Date: 06/11/2012 Expiration Date: 06/10/2013 Capacity: 137 Program Type: AGED ALZHEIMERS 1

4 II. ALLEGATION(S) Resident received the wrong medications. III. METHODOLOGY 07/02/2012 Special Investigation Intake 2012A /03/2012 Special Investigation Initiated - On Site On-site inspection included reviewing records and interviewing staff members and residents. 07/24/2012 Contact - Telephone call made Telephoned staff member 07/25/2012 Contact - Telephone call received Received telephone call from staff member 08/13/2012 Exit Conference Conducted with authorized representative of Farmington Hills Inn, Julie Norman, by telephone. ALLEGATION: Resident received the wrong medications. INVESTIGATION: The Director of Nursing for Farmington Hills Inn, Patricia Clark, reported via a MEDICATION RELATED INCIDENT REPORT form that at 8:45 am on 6/29/2012 staff member Katina Mayweather reported a medication error that Resident B had received the wrong medications. The MEDICATION RELATED INCIDENT REPORT indicated: Trainee gave [Resident A s] medication to [Resident B]. The medications given to Resident A were Keppra, Lopressor, Zoloft, Digoxin, and Plavix. Resident B s physician was notified of the incident at 8:50 am on 6/29/2012 and the physician indicated: Monitor residents [sic] blood pressure and pulse for the next 24 hours. None of extra meds are toxic resident just needs to be monitored. Resident B s relative (B1) was notified of the incident at 9:15 am on 6/29/2012. The action taken: BP [and] pulse every hour x 24. Monitor. Corrective measures put in place to prevent this incident from recurring were not included in the report. I interviewed staff member Katina Mayweather who stated that she came into work at 5:55 am on 6/29/2012 and saw that the staff work schedule indicated that she would be training staff member Laurice Lomax. Ms. Mayweather said Ms. Lomax accompanied/assisted her with the morning care of the residents and after 2

5 completing the morning care of residents, she and Ms. Lomax went to the dining room to administer medications. Ms. Mayweather said she and Ms. Lomax both administered medications in the dining room and towards the end of the breakfast meal in the dining room residents began coming to her asking when they would be receiving/getting their eye drops. Ms. Mayweather said residents were asking about the eye drop medication because normally she would have administered this medication along with the other medications being administered. Ms. Mayweather stated that Ms. Lomax was preparing to administer Resident A s medications and she asked Ms. Lomax if she knew Resident A to which Ms. Lomax answered yes. Ms. Mayweather said she did not think that Ms. Lomax would proceed with administering the medication to Resident A without having her observe the process because before she was distracted by the residents Ms. Lomax had waited for her to ensure that she was giving the medications to the right residents. Ms. Mayweather said she turned around after answering the residents questions and Ms. Lomax said that she had given Resident A her medications. Then a few seconds later, Ms. Mayweather stated that Resident A came to the medication cart and asked for her medications. Ms. Mayweather then asked Ms. Lomax if she had given Resident A the medications and Ms. Lomax said yes she had given Resident A her medication. Ms. Mayweather said she then asked Ms. Lomax to show her the resident who had been given the medications and Ms. Lomax showed her Resident B. Ms. Mayweather said she then called Ms. Clark, measured Resident B s vital signs, and monitored Resident B until Ms. Clark arrived at 9:00 am. Ms. Mayweather said she notified B1 and Resident B s physician of the incident. Resident B s vital signs were measured every hour. I interviewed Ms. Lomax who stated that she was being trained to administer medications by Ms. Mayweather when the medication error occurred. Ms. Lomax stated that she and Ms. Mayweather were in the dining room administering medications and Ms. Mayweather pointed to the dining table where Resident A was seated. Ms. Lomax said she went to the wrong table because she got Resident A and Resident B mixed-up/confused. Ms. Lomax stated that Ms. Mayweather was not with her as she was administering the medications because Ms. Mayweather was administering medications to another resident. Ms. Lomax said that this medication error was her only medication error. I interviewed Ms. Clark who stated that she was contacted by Ms. Mayweather who reported the incident. After receiving this information from Ms. Mayweather, Ms. Clark stated that she called the pharmacy and Resident B s physician who said to monitor Resident B by measuring her pulse and blood pressure every hour. Ms. Clark said she then counseled Ms. Lomax and Ms. Mayweather and told Ms. Mayweather that she could not leave the staff member that she was training unobserved. I interviewed Resident B who stated that she did not remember the incident. 3

6 According to the employee s records, Ms. Mayweather was hired to work at Farmington Hills Inn on 3/19/2012 and had completed the required training to administer medications. Ms. Lomax was hired to work at Farmington Hills Inn on 6/23/2012. APPLICABLE RULE R Resident medications. (1) Medication shall be given, taken, or applied pursuant to labeling instructions or signed orders by the prescribing licensed health care professional. ANALYSIS: CONCLUSION: Medications were not given or taken pursuant to the signed orders or labeling instructions by the prescribing licensed health care professional. Resident A received Resident B s medications of Keppra, Lopressor, Zoloft, Digoxin, and Plavix on 6/29/2012. VIOLATION ESTABLISHED ADDITIONAL FINDING: APPLICABLE RULE R Reporting of incidents, accidents, elopement. (1) The home shall complete a report of all reportable incidents, accidents, and elopements. The incident/accident report shall contain all of the following information: (e) The corrective measures taken to prevent future incidents/accidents from occurring. ANALYSIS: CONCLUSION: The corrective measures taken to prevent future medication error incidents from occurring was not indicated in the medication related incident report. VIOLATION ESTABLISHED 4

7 IV. RECOMMENDATION Contingent upon receipt of an acceptable corrective action plan, I recommend no change in the license status. 8/13/12 Loma M Campbell Date Licensing Staff Approved By: 8/13/12 Betsy Montgomery Date Area Manager 5