St Elizabeth Hospital

Summary: MDH found the licensee failed to ensure the service plan included all required content for three of three residents (R1, R2, and R3).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the service plan included all required content for three of three residents (R1, R2, and R3). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment which included the required content for three of three residents (R1, R2 and R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment which included the required content for three of three residents (R1, R2 and R3). [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to develop an individualized medication management plan with the required content for three of three residents (R1, R2, and R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop an individualized medication management plan with the required content for three of three residents (R1, R2, and R3). [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure the registered nurse documented resident-specific instructions for one of three residents (R3) whose medication administration was delegated to unlicensed personnel.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the registered nurse documented resident-specific instructions for one of three residents (R3) whose medication administration was delegated to unlicensed personnel. [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure medications were administered per prescriber's orders and failed to ensure medication administration was documented accurately for one of three residents (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered per prescriber's orders and failed to ensure medication administration was documented accurately for one of three residents (R2). [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Summary: MDH found the licensee failed to ensure documentation of medication set up included all the required content for three of three residents (R1, R2, and R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure documentation of medication set up included all the required content for three of three residents (R1, R2, and R3). [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for two of two employees (unlicensed personnel (ULP)-C, ULP-D). [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to ensure medications were secure and permitted access to only authorized personnel.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were secure and permitted access to only authorized personnel. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure [...]”

Rule cited: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to document in the resident's record the disposition of the medications as required for one of one discharged resident (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medications as required for one of one discharged resident (R4). [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of two residents (R1 and R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for two of two residents (R1 and R3). [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Summary: MDH found the licensee failed to ensure care and services were provided according to acceptable health care and medical or nursing standards for one of one resident (R1) with side rails.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure care and services were provided according to acceptable health care and medical or nursing standards for one of one resident (R1) with side rails. [...]”

Rule cited: “(a) Residents have the right to care and assisted living services that are appropriate based on the resident's needs and according to an up-to-date service plan subject to accepted health care standards.”

Summary: MDH found the licensee failed to ensure nurse delegated procedures were followed by one of one unlicensed personnel (ULP-C) observed during medication administration.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure nurse delegated procedures were followed by one of one unlicensed personnel (ULP-C) observed during medication administration. [...]”

Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”