The Atrium at Drum Hill

EOEA reviewed the Residence’s dietary plan reviews from 2022 through the date of compliance review to confirm consistency with the most recent edition of Dietary Guidelines.

Current Resident menus were missing designations of which selections meet the daily recommend allowances of sodium, sugar and fat content as established by the Food and Nutrition Board of the of the National Research Council of the National Academy of Sciences.

EOEA reviewed five (5) Resident Records to determine compliance with requirements for the Screening and Assessment, Service Plan Development and Service Plan Requirements.

Four (4) records were without documentation to confirm the initial assessment was conducted by a nurse.

Three (3) records were missing documentation of assessment results for Resident allergies.

Three (3) records were missing documentation of assessment results for Resident diagnosis.

Two (2) records were missing documentation of assessment results for Resident dietary needs.

Documentation of individualized enrichment activities provided to the resident was missing in three (3) Special Care Residence (SCR) records.

EOEA reviewed the Residence records of two (2) Residents utilizing bed rails / U-bars or similar devices for the period of 2022 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.

Documentation of an assessment conducted by a physical/occupational therapist every six months was missing for two (2) Residents utilizing a bed rail/ U-bar for the calendar years reviewed.

EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the calendar years 2022 through the date of the Compliance Review.

Resident Safety Assurances

Documentation of a bi-annual review of the Evidenced Informed Falls Prevention Program, required per Residence policy, was missing in the 2022 calendar year reviewed.

EOEA reviewed the Residence records and incident reports from June 2022 through the date of the Compliance Review to determine whether the Residence complied with the requirement to qualifying incidents to EOEA within 24 hours after the occurrence of the incident or accident.

The Residence filed 49 incident reports greater than 24 hours after the incident or accident.

EOEA reviewed five (5) Resident records to determine compliance with record requirements.

Inconsistent documentation of significant occurrences in the Progress Notes for two (2) Residents.

EOEA reviewed the documentation maintained in two 90-day correspondence logs to communicate information necessary to maintain the continuity of care for Residents in the Residence.

The logs did not consistently document all significant or pertinent information necessary to maintain the continuity of care for all Residents.

EOEA reviewed the records of five (5) Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident.

Five (5) records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care (PC) services, at the time of move-in or at the time of change in the Resident’s condition.