Norwich Springs Health Campus

Based on observation, medical record review, staff interview, review of facility policy, and review of manufacturer directions, the facility failed to prime an insulin pen per the manufacturer instructions prior to administration to the resident. This affected one (Resident #10) of one resident observed for insulin administration. The facility identified five residents on insulin pen therapy. The facility census was 33.

Findings include:

Review of medical record for Resident #10 revealed and admission date of 3/8/24. Diagnoses include diabetes mellitus (DM) type II and Alzheimer's disease.

Observation on 02/24/25 at 9:15 A.M. revealed Licensed Practical Nurse (LPN) #159 administered medications to Resident #10. LPN #159 turned the dial to six units on the insulin pen. LPN #159 did not expel insulin from the pen to prime prior to dialing six units. LPN #159 then administered the insulin to Resident #10.

Interview on 2/24/25 at 9:15 A.M. with LPN #159 stated dial was turned to six units (correct dose) and confirmed no prior insulin was expelled to prime the pen. LPN #159 stated two units should have been primed prior to dialing to ordered dose.

Review of the facilities policy titled AL-Medication Administration Guidelines (dated 05/23/18) revealed medications are to be given in accordance with the directions on the prescription or the physician's or other authorized prescriber's orders.

Review of Admelog's website found at https://www.admelog.com/how-to-use-admelog (undated) revealed to do a safety test to make sure you get the correct insulin dose by expelling two units prior to administration.

Based on review of the facility's Self-Reported Incident (SRI), review of facility policy, record review and staff interview, the facility failed to ensure Resident #27 free from abuse. This affected one (Resident #27) of five residents reviewed for abuse. The facility census was 33.

Findings include:

Medical record review revealed Resident #27 was admitted to the facility on 06/30/23 with diagnosis of metabolic encephalopathy.

Review of the facility's SRI dated 02/10/25 revealed Resident #27 alleged $50.00 was missing from her purse. Resident #27 stated she felt uneasy about her money missing. The Administrator asked Resident #27's son to check Resident #27's debit card account and checkbook that was in Resident #27's possession. The son reviewed the debit card account and found suspicious activity from 01/21/25 to 01/29/25 with most transactions being after 10:00 P.M. and some transactions being out of state. Review of the resident's debit card statement revealed there was $337.93 of suspicious spending on Resident #27's debit card. The Local Police Department (LPD) was notified and the LPD started their own investigation. LPD was going to work with local businesses to try and pull camera footage to see if they can match anyone up. On 02/20/25, the facility was notified Licensed Practical Nurse (LPN) #350 was arrested for identity fraud.

Interview on 2/24/25 at approximately 8:30 A.M. with the Administrator stated LPN #350 was arrested by the LPD for Resident #27's identity fraud on 02/20/25. The Administrator stated LPN #350 was terminated from the facility.

Review of the facility's abuse policy last revised 08/29/19 revealed the facility developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Misappropriation of property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on record review and staff interview, the facility failed to perform twelve fire drills on each shift on a quarterly basis and failed to evacuate residents during the fire drills. This had the potential to affect 22 of 22 residents residing in the facility.

Findings include:

Review of fire drill records for calendar year 2023 the following fire drills were held on first shift: 03/18/23 at 7:05 A.M., 06/24/23 at 9:15 A.M., 09/19/23 at 9:40 A.M. The following fire drills were held on second shift: 01/17/23 at 3:15 P.M., 07/12/23 at 3:10 P.M., 10/27/23 at 5:15 P.M. The following fire drills were held on third shift: 02/15/23 at 5:00 A.M., 05/16/23 at 6:00 A.M., 08/22/23 at 6:00 A.M. Further review of the fire drill records for 2023 revealed no residents were evacuated as part of the fire drills.

Interview on 01/24/24 at 12:15 P.M. with Director of Plant Operations (DPO) # 17 confirmed the facility only had record of nine fire drills held for calendar year 2023 and that no residents were evacuated to a safe area during any of the fire drills.