AL A Country Place Senior Care Center

Transcription

1 RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF HEALTH CARE SERVICES MIKE ZIMMER DIRECTOR June 4, 2015 Jennia Woodcock Community Health Care Management 1805 E Jordan Mt. Pleasant, MI RE: License #: Investigation #: AL A Country Place Senior Care Center Dear Ms. Woodcock: 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 contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please contact the local office at (810) Sincerely, Diane L Stier, Licensing Consultant Bureau of Children and Adult Licensing 1919 Parkland Drive Mt. Pleasant, MI (989) Enclosure P.O. BOX LANSING, MICHIGAN (517)

3 MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: AL A Complaint Receipt Date: 05/06/2015 Investigation Initiation Date: 05/06/2015 Report Due Date: 06/05/2015 Licensee Name: Licensee Address: Community Health Care Management 2033 Westbrook Ionia, MI Licensee Telephone #: (989) Administrator: Licensee Designee: Name of Facility: Facility Address: Jennia Woodcock Jennia Woodcock Country Place Senior Care Center 1805 E. Jordan Road Mount Pleasant, MI Facility Telephone #: (989) Original Issuance Date: 02/01/1996 License Status: REGULAR Effective Date: 03/31/2014 Expiration Date: 03/30/2016 Capacity: 20 Program Type: AGED MENTALLY ILL 1

4 II. ALLEGATION(S) Resident A's Ambien prescription was refilled but cannot be found. Additional Findings Violation Established? Yes Yes III. METHODOLOGY 05/06/2015 Special Investigation Intake 2015A /06/2015 Special Investigation Initiated - Telephone CMH Case manager 05/07/2015 Inspection Completed On-site Records, interviews 05/07/2015 Contact - Document Received Copies of resident records 05/07/2015 Exit Conference Licensee Designee ALLEGATION: Resident A's Ambien prescription was refilled but cannot be found. INVESTIGATION: On 5/6/15, case manager (CSM) Katie Hohner, from CMH for Central Michigan, reported that she had moved Resident A from Country Place Senior Care to another facility on 5/1/15. CSM Hohner said that Resident A had only a couple of his Ambien pills left, which were prescribed as needed (PRN). CSM Hohner said that the staff at the new facility called the pharmacy to have the Ativan refilled, but they were told the prescription could not be refilled again because it had just been refilled. CSM Hohner said that pharmacy records showed that the prescription was delivered to the AFC home, but the new prescription was never documented at Country Place. On 5/7/15, Licensee Designee Jennia Woodcock said she thought perhaps that a new bubble pack of Ambien had been sent with Resident A but that it may have been labeled with the generic name for the medication, Zolpidem Tartrate. On 5/7/15, CSM Hohner reported that there was no bubble pack of the generic form of Ambien in the medications she transported to Resident A s new AFC home, and Resident A had no access to his medications while in transport to the new AFC home. CSM Hohner said that the medications were in a bag on the floor of the car behind her 2

5 during the ride, and she gave them directly to staff at the new home when they arrived there. On 5/7/15, I examined Resident A s Medication Administration Records for April and May The April Medication Administration Record showed that Resident A requested and was given PRN Ambien on 27 of 30 days during the month. The May Medication Administration Record was blank (as it should have been) but were signed by CSM Katie Hohner as Received 5/1/15. On 5/7/15, staff Cathy Mayes said that there were only a few of Resident A s Ambien left when he moved from the facility. Ms. Mayes said there was no full or new bubble pack card of the medication, generic or otherwise. Ms. Mayes said that medications are generally delivered in the evening or night, and the delivery person takes them to Unit 3 (another licensed facility on the same complex). Ms. Mayes said that staff on Unit 3 is supposed to call the other facilities and let them know there are medications to pick up. Ms. Mayes said that they have a new delivery person from the pharmacy, however, who has been having the Unit 3 staff sign for the medications but then has been taking the medications to the proper facility afterward. On 5/7/15, staff Alexis Myers reported that she worked on 4/27/15. When asked how medications are delivered to the facility, Ms. Myers said that the pharmacy delivery person generally goes to Unit 3, which is closest to the main entrance of the complex, and give the new medication bubble packs to the staff person along with a copy of the sticker that goes with it, which lists the medication, the dose, time of day, etc. Ms. Myers said that once a medication is received in the facility where the resident lives, the staff there count it in with the other staff on duty and then put the medication in the locked cart. Ms. Myers said that if Resident A s Ambien had been delivered to Country Place Senior Care on 4/27/15, she would have signed it in. Ms. Myers said, It would have be written on the med county sheet and signed and initialed with the time, and I would have added the pills to the med count. Ms. Myers said she had no recollection of a new bubble pack of Ambien coming in on 4/27/15, even though other medications were delivered and logged in. On 5/7/15, Manager Jamie Aasved reported that she orders the medications for the facilities, and that she sends a text message to the pharmacy with a list of needed medications. During the interview, Ms. Aasved called the pharmacy and verified that she ordered Resident A s Ambien refill on 4/27/15. Ms. Aasved said that pharmacy reported that it was delivered to Country Place on the same day. On 5/7/15, I received and reviewed a copy of the form which the pharmacy faxed to Country Place showing that staff Karen Mealer, who was working in Unit 3 on the evening of 4/27/15, signed as receiving Resident A s prescription refill on 4/27/15. I reviewed documentation in Country Place Senior Care and found that no additional Ambien were logged onto the medication count sheet for Resident A on 4/27/15 or any other date in April. I also noted, however, that a prescription for Resident B was documented as having been received that day (4/27/15) and the additional pills were 3

6 added to the medication count sheet for that medication and initialed by staff Alexis Myers. On 5/7/15, staff from Life Care Pharmacy reported that Resident A s prescription for Ambien had been filled again on 5/5/15, according to insurance records. On 5/7/15, CSM Katie Hohner confirmed that Resident A s Ambien prescription had been refilled on 5/5/15 and Resident A had been receiving the medication since that time at the new AFC home. APPLICABLE RULE R Resident medications. (6) A licensee shall take reasonable precautions to insure that prescription medication is not used by a person other than the resident for whom the medication was prescribed. ANALYSIS: CONCLUSION: Although the licensee s staff in Unit 3 signed for Resident A s Ambien refill when delivered by the pharmacy on 4/27/15, the licensee s staff did not then keep possession of the medication. There is no way to determine what happened to the medication after staff Karen Mealer signed for it, since the pharmacy personnel then supposedly took the medication to Country Place Senior Care. It seems unlikely that staff at Country Place Senior Care actually received the medication at that time, since they did receive and correctly document a refill for Resident B on that same evening. The licensee did not take reasonable precautions when allowing the medication to be out of the licensee s control once it was first delivered by the pharmacy and signed for by the licensee s staff. VIOLATION ESTABLISHED ADDITIONAL FINDINGS: INVESTIGATION: While examining the records for medications delivered to Country Place Senior Care on 4/27/15, I found that a refill of Norco was delivered for Resident B on that date. I examined the medication count sheet and found that Resident B was out of Norco as of 3 PM on 4/26/15. The new refill of 90 pills was logged into the medication count sheet at 8:30 PM on 4/27/15. I received and reviewed a copy of Resident B s Medication Administration Record for April Resident B was prescribed Norco/APAP/Hydrocodon to be taken one tablet 4

7 twice daily. According to the documentation, Resident B did not receive the Norco on the night of 4/26 or the morning of 4/27. Staff noted that they were awaiting refill. On 5/7/15, Manager Jamie Aasved reported that on Saturday afternoon, 4/25/15, staff reported that Resident A had only one Norco pill left. Ms. Aasved said she asked staff Cathy Mayes about it that day, because staff said they had told Cathy about the need for a refill on Friday, 4/24. According to Ms. Aasved, Ms. Mayes said she forgot about the refill being needed. Ms. Aasved said she immediately called Mo from Life Care Pharmacy and told him that Resident B had only one Norco left and that they needed the refill. According to Ms. Aasved, the pharmacy and she arranged that she would leave the prescription for the refill with staff in Unit 3, and the pharmacy would deliver the refill that night (4/25/15). Ms. Aasved said she did not know until Monday, 4/27/15, that the medication had not been delivered over the weekend. APPLICABLE RULE R Resident health care. (1) A licensee, with a resident's cooperation, shall follow the instructions and recommendations of a resident's physician or other health care professional with regard to such items as any of the following: (a) Medications. ANALYSIS: CONCLUSION: Due to staff not placing a refill order for Resident B s Norco in a timely manner, Resident B missed two doses of his Norco medication. VIOLATION ESTABLISHED During an exit conference on 5/7/15, Licensee Designee Jennia Woodcock reported that she will revise the facility s policy regarding medications so that medication deliveries are only signed by the staff who receives and logs in the medication in each of the licensee s facilities. Ms. Woodcock said she will also assure that needed medication refills are ordered in a more timely fashion. 5

8 IV. RECOMMENDATION Pending receipt of an acceptable corrective action plan, I recommend continuation of the current status of the license of this AFC adult large group home (capacity 13-20). Diane L Stier Licensing Consultant May 26, 2015 Date Approved By: June 2, 2015 Mary E Holton Date Area Manager 6