Ruth's House

EOEA reviewed the Residences records and submitted incident reports from the last quarter of calendar year 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 59 incident reports greater than 24 hours after the occurrence of the incident during the period reviewed.

EOEA reviewed the Personalized Emergency Response procedures developed to provide timely assistance to a Resident in the event of an emergency needs situation.

In the months of October 2022, August 2023, and May 2024 there were 187 e-call response times over the seven minutes required by the Residence policy.

The Residence has chosen to manually document hourly safety checks of Residents living in the Special Care Residence (SCR) to comply with the regulations to provide timely assistance to a Resident in the event of an emergency needs situation.

Documentation of hourly checks in the Specialized Care Residence neighborhood for May 2024, had multiple instances where staff failed to document the hourly safety checks of the SCR Residents during the hours of 7:00pm and 7:00am.

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 year of 2022(last quarter) and 2023.

Documentation of the date the audit was completed on was missing in 2022 and 2023 calendar years.

Resident Safety Assurances

Documentation of the date the audit was completed on was missing in calendar years 2022, 2023.

Documentation of a target date for follow-up was missing in calendar years 2022 and 2023.

Documentation of staff responsible for follow-up was missing in calendar year 2023.

Documentation of monitoring the effectiveness of the Evidence Informed Falls Prevention Program as part of the Resident annual safety review process was missing for calendar years 2022 and 2023.

The Residence was missing the follow up action for set target date and staff responsible for follow-up in the last quarter of calendar year 2022 and calendar 2023.

EOEA observed two RCA staff and one nurse providing medication assistance to six Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM and LMA:

One Resident had a family filled medication cassette missing a label with resident name and room number.

One Resident had three prescription bottle medications located next to the sink unsecured in the resident room.

EOEA reviewed the records of six Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.

EOEA reviewed the Residence records of 12 Residents utilizing bed rails/ U-bars or similar devices for the period of 2023 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 confirming that the Resident can independently navigate around the bed rail/U-bar were missing for four Residents for the calendar year 2023 and 2024.

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

The Residence did not use the Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents

EOEA reviewed the personnel records of six staff members to determine compliance with Health Screening requirements.

Five records were missing documentation to confirm receipt or declination of the seasonal influenza vaccine

EOEA reviewed the Special Care Unit. All Special Care Residences shall be administered in accordance with the following safeguards: 1. The Residence shall develop and implement policies and procedures to assess and reduce the risk of potential hazards in the physical environment related to the special characteristics of the population. 2.Entry and exit doors in the common use areas within Special Care Residences shall be secured in accordance with local, state, and federal laws and regulations. All doors must automatically unlock in case of fire, power outage or emergency situation. Such policies and procedures must include an annual written statement describing in detail how the physical characteristics of any Special Care Residence have been or will be modified to promote the safety of its Residents.

EOEA observed the Special Care Unit:

The Special Care Unit, EOEA noted chemicals not secured in the common kitchen area in the Special Care Unit.

The Special Care Unit entrance and exit doors in the common areas within the Special Care Residence were not secured with alarms at the time of the Compliance Review.

Corrective Actions.