- Complaint #AR00027919 was unsubstantiated.
- Regs out of compliance –
- N 120 – Facility failed to meet the requirements for Condition of Participation by failing to ensure a policy and procedure related to the vaccination of staff, appropriate interventions were in place to mitigate the spread of Covid-19, and only 53 percent of staff were vaccinated.
- N 156 – Facility failed to ensure a Physician’s order for a physical restraint was signed by the physician for 1 client who was physically restrained.
- Plan of Correction – Policy was implemented (IC35/Employee Health COVID Control Plan) and database developed to track vaccination status of staff. The attending physician was retrained regarding CMS guidelines and DFC Policy PC 11, and DocuSign program was purchased and activated to expedite signatures. The Director of Nursing will in-service all nursing staff on policies and DocuSign application and will review each seclusion and restraint to ensure signatures.
PRLU or OLTC
Complaint Survey with POC