Inspection Reports for Oaks at Dalton
2470 Dug Gap Rd, Dalton, GA 30720, United States, GA, 30720
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Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 17, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00211529 and #GA00211734. The investigation started on 2021-03-11 and was completed on 2021-03-17.
Findings
The facility failed to ensure that staff did not assist with, provide supervision of self-administered medications, or administer any medications without a physician's order specifying clear instructions for use for 1 of 3 sampled residents (Resident #1). Resident #1 was given Seroquel medication not prescribed to him/her, resulting from a medication error where the medication was intended for another resident.
Complaint Details
The investigation was complaint-related, investigating intake #GA00211529 and #GA00211734. The complaint involved medication errors where Resident #1 was given medication not prescribed to him/her. The facility notified the responsible party about the medication error on 1/27/2021, and Resident #1 has seen the doctor weekly since the error.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff did not assist with or administer medications without a physician's order specifying clear instructions for use for Resident #1. | G |
Report Facts
Medication dosage: 25
Dates of medication administration: From 2020-11-11 to 2021-01-27
Investigation dates: Investigation started 2021-03-11 and completed 2021-03-17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Med Tech | Med Tech on duty who added medication to MAR without hard copy prescription |
| Staff C | Interviewed staff who explained medication error and process |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 22, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00207384, which involved an allegation of medication error where a Medication Technician administered insulin prescribed for another resident to Resident #1.
Findings
The facility failed to ensure Resident #1 received appropriate care as Staff B administered insulin not prescribed for Resident #1, resulting in the resident being transferred to the emergency room for evaluation and treatment. Interviews and record reviews confirmed the medication error and subsequent hospital admission for hypoglycemia monitoring.
Complaint Details
Investigation started on 2020-09-09 and completed on 2020-09-22. The complaint was substantiated based on record review and interviews confirming the medication error and resulting harm to Resident #1.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medication Technician administered insulin prescribed for another resident to Resident #1. | J |
Report Facts
Date of incident: Aug 7, 2020
Units of insulin administered: 8
Blood sugar level: 100
Date admitted to hospital: Aug 7, 2020
Date hired: Sep 17, 2018
CMA certificate expiration: Oct 23, 2021
Date resident admitted: Aug 7, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medication Assistant | Named in medication error finding for administering insulin prescribed for another resident |
| Staff A | Interviewed regarding Staff B's medication error and protocol failure |
Inspection Report
Monitoring
Deficiencies: 0
Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Original Licensing
Deficiencies: 0
Jan 23, 2020
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 22, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the annual inspection with an on-site visit made to the Community on 1/22/18.
Findings
No rule violations were cited as a result of the inspection.
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 18, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the assisted living facility Morningside of Dalton.
Findings
The inspection identified multiple deficiencies including failure to provide evidence of family involvement in care plan development for 6 of 8 sampled residents, failure to follow physician's medication orders resulting in a double dose medication error for one resident, lack of quarterly drug regimen reviews by a licensed pharmacist, and failure to complete annual competency reviews for certified medication aides.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide evidence of family involvement in the development of the residents care plan for 6 of 8 sampled residents. | SS= D |
| Failure to follow the written physician's order for 1 of 9 sampled residents, resulting in a double dose of medication. | SS= D |
| Failure to secure the services of a licensed pharmacist to perform quarterly drug regimen reviews, remove expired drugs, monitor medication handling, and establish policies for drug therapy. | SS= D |
| Failure to complete comprehensive clinical skills competency reviews annually for certified medication aides for 1 of 6 sampled staff. | SS= D |
Report Facts
Residents with missing family involvement in care plan: 6
Residents sampled for medication order compliance: 9
Staff sampled for competency reviews: 6
Dates of medication error: Jan 29, 2017
Date of disciplinary action record: Feb 4, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in medication error for administering double dose due to looking at wrong date on MAR | |
| Staff H | Certified Medication Aide | Lacked annual competency reviews for 2015, 2016, 2017 |
| Staff A | Interviewed regarding compliance and medication review issues | |
| Staff B | Interviewed regarding compliance and medication error notification |
Inspection Report
Follow-Up
Deficiencies: 0
Dec 6, 2016
Visit Reason
The visit was conducted as a follow-up to the 6/13/2016 annual inspection and complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
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