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10/02/2020 Complaint Survey with POC, Workload Report, 11.23.20 Revisit Survey

  • Complaint #AR00025540 substantiated.
  • Regs out of compliance –
    • N 100 Use of Restraint and Seclusion, N 126 Protection of Residents –
      • Failed to ensure a chemical restraint was not administered without documentation of the attempt to allow time for the client to calm or the use of less restrictive interventions before the administration of a chemical restraint for 10 clients.
    • N 144 Orders for Use of Restraint or Seclusion –
      • Failed to ensure there was an active order for use of restraint and/or seclusion procedure for client.
  • Plan of Correction: The Director of Nursing reviewed resident records and facility policies and provided training to all nurses. Random audits are also completed.
  • 09/27/20-10/02/20 Survey Team Composition and Workload Report. 2 staff – 30283= 3 onsite (12am-8am), 32.5 on-site (8am-6pm) 09/27-10/02, 4.75 travel,25 offsite report. Staff 2 (21299) 3 on-site (12am-8am), 12.25 on-site (8am-6pm) 09/27-09/29, 4 travel, 18 off-site reports.
  • Revisit conducted on 11/23/20 for all deficiencies cited on 10/2/20; All deficiencies corrected with no new noncompliance found.
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