The Wellington at Springfield

EOEA reviewed the Residences records and submitted incident reports from 2022 through the day of the compliance review for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident’s health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident during the period reviewed.

The Residence filed 97 incident reports greater than 24 hours after the occurrence of the incident during the period 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 calendar years 2022 and 2023.

Documentation of Service Plan reviews for calendar years 2022 and 2023 did not note specific findings, follow-up action for set target date, staff responsible for follow-up and documented outcomes.

Resident Safety Assurances

Documentation of Evidence Informed Falls Prevention Program monitoring effectiveness of the program was missing for calendar years 2022 and 2023.

EOEA reviewed the Residence’s quarterly medication documentation audits for the calendar years 2022 and 2023 through the date of Compliance Review to ensure compliance with SAMM and LMA protocols and Residence policies.

The Residence was missing the first two quarters for calendar year 2023 and was missing documentation of follow- up action for the date audit was completed, clear findings, follow-up action for set target date, staff responsible for follow-up, documented outcome was missing for 2023 calendar year.

EOEA observed two Care Manager staff providing medication assistance to five Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:

SAMM:

Two resident’s family filled medication cassettes were not labeled with the Resident’s names and dates.

One resident’s SAMM medication box contained 1 loose pill and was missing documentation on SAMM MAR sheet for the reason of medication omission.

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

Five records were without documentation to confirm the initial assessment was conducted by a nurse.

Four records were missing documentation of the Legal Representative and the scope of authority.

Four records were missing documentation of a Service Plan reassessment require within 30-days after the commencement of residency.

Four records were missing documentation of a reassessment and service plan review completed every six-months.

Four SCR service plan records were missing Documentation of individualized enrichment activities provided to the resident.

Four records were missing documentation of supervised access cooking capacity.

EOEA reviewed response times of the emergency response system from calendar year 2023 through date to the compliance review to determine Service Coordination requirements.

The Residence is not demonstrating an effective means ensuring reasonable staff response times to Resident requests for assistance for all years reviewed.

In the months of August 2023 and November 2023 there were 305 e-call response times over the ten minutes required by the Residence policy.

EOEA reviewed the Residence’s documentation for evidence of Dietary Reviews at least every six months.

Documentation of a dietitian’s review completed every six months was missing for the fourth quarter of calendar year 2022.

EOEA reviewed the Controlled Substance (CS) policy and procedure intended to prevent the theft or diversion of controlled substances prescribed to Residents who participate in SAMM or LMA.

EOEA observed staff was not following the Residence Controlled Substance count audits in accordance with the current Residence Controlled Substance count policy.

Three Residents medication storage units contained as needed (PRN) medication. Upon observation of the Residence controlled substance practice, it was discovered that the residents were without supply of the PRN medication.

EOEA reviewed the current 90-day Correspondence Logs, required to communicate information necessary to maintain the continuity of care for all Residents.

The Residence did not consistently document for both the Traditional and Special Care Residence’s correspondence logs were missing information necessary during each 24-hour period for the continuity of care for Residents.

EOEA reviewed the records of 7 Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers.

Seven records were without documentation to support that Introductory Visits were consistently conducted by a nurse.

EOEA reviewed the Residence’s documentation for evidence of compliance with training needs assessment regulations.

Documentation to support that the Residence has conducted a training needs assessment in the 2022 calendar year, was missing.