Ohio Valley Manor Care Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with diagnoses including atrial fibrillation, protein calorie malnutrition, dementia, depression, and transient ischemic attacks was prescribed Diltiazem 180 mg daily by their primary care provider. However, facility staff transcribed the order incorrectly, entering Dilantin 180 mg instead of Diltiazem into the resident's medication orders. As a result, the resident received Dilantin 180 mg rather than the intended Diltiazem on the following day. The error was identified through a review of the medical record, medication administration record, and the facility's medication error form, which confirmed the transcription mistake. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance, leading to the administration of the wrong medication to the resident.

Plan Of Correction

Resident was assessed for changes in condition and any side effects from the medication and none were noted. Assessment was completed by RN unit manager and evaluated by LPN staff nurses on 4/25/25. No new interventions needed. The physician was notified on 4/25/25 and no new orders provided. There was no change in the resident's condition. The facility DON and/or designee completed an audit of orders for patients on Dilantin and/or Diltiazem to ensure that orders are correct. The audit was completed on 6/26/25. All nurses in the facility will be educated on ensuring that appropriate medication is picked from the drop-down box in the EMR and to be aware of look-alike names such as Dilantin and Diltiazem. Education will be completed by DON and/or designee and will be completed by 7/10/25. The DON and/or designee will audit new medication orders on 2-3 residents per unit weekly for 4 weeks. The results of the audit will be forwarded to the QAPI Committee to determine next steps.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to file a Self Reported Incident (SRI) with the State Agency following an allegation of sexual abuse involving a resident. The resident, who had a history of bipolar disorder, anxiety disorder, and dementia, was admitted to the facility and later referred to a gynecologist due to vaginal bleeding. The gynecologist's assessment raised concerns about a potential sexual assault, as the resident had reported being sexually active with her husband and had experienced bleeding after intercourse. Despite these concerns, the facility did not report the incident to the State Agency as required by their policy. The facility's policy mandates that any event involving abuse or serious bodily injury should be reported to the State Agency immediately, or no later than two hours after the allegation is made. However, an interview with the Administrator confirmed that no SRI was filed following the gynecologist's documented allegation of potential sexual assault. This oversight represents a deficiency in the facility's compliance with state reporting requirements, as investigated under Complaint Number OH00162528.

Plan Of Correction

Resident has had no further vaginal bleeding. Skin assessment of resident was completed on 3/3/25 by staff nurse with no suspicious findings. Medical record was reviewed by ADON on 3/7/25 and resident has had no decline in status as evidenced by stable mood and behavior, no decline in intakes, and no other decline in status. All current resident records were reviewed by ADON, unit manager or MDS to identify any suspicious injuries/injuries of unknown source. None were identified. This review was completed on 3/7/25. Administrator reviewed facility complaints for the last 3 months on 3/7/25 and there were no complaints that were suspicious for abuse. The facility did not identify any other reportable events from the complaints or medical record reviews. Administrator and DON were educated on 3/11/25 on reporting to State Agency as outlined in the facility policy by the Corporate DON. See inservice attached. To ensure ongoing compliance, the facility administrator will review all complaints and any injuries without a known cause weekly with Corporate DON x 4 weeks. The results of these reviews will be forwarded to the QAPI Committee to determine a schedule for ongoing monitoring or additional interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the resident environment was free of potentially hazardous substances, which led to an incident involving a resident with severely impaired cognition. Resident #130, who had multiple diagnoses including frontotemporal neurocognitive disorder and dementia, was found in possession of two medications, Wellbutrin and Adderall, that belonged to a State tested Nursing Assistant (STNA). The medications were left unattended in the resident dining room by STNA #30, who had left her purse containing the medications on a table while she took her lunch break. A visiting family member alerted staff that Resident #130 was looking through the purse, and the resident was subsequently found in his room with the medication bottles, one of which was open. The resident was sent to the hospital for evaluation and possible treatment for ingestion of the medications, but blood tests revealed no ingestion had occurred, and the resident returned to the facility with no new orders. Interviews with the Director of Nursing (DON), Administrator, and Registered Nurse (RN) confirmed that STNA #30 did not properly secure her personal belongings, leading to the resident's access to the medications. The facility's employee handbook states that all employees are responsible for securing their personal property, but this protocol was not followed in this instance. The deficiency was investigated under Complaint Number OH00153629 and represents noncompliance with ensuring a safe environment free from accident hazards.