Inspection Reports for Springdaile Assisted Living
4315 Holder Rd, Durham, NC 27703, United States, NC, 27703
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Inspection Report
Annual Inspection
Deficiencies: 1
Feb 6, 2025
Visit Reason
The Adult Care Licensure section conducted an annual and follow-up survey on 02/06/2025 to assess compliance with medication order verification requirements.
Findings
The facility failed to clarify an order for one resident involving an anti-psychotic medication, clozapine. There was no documentation that the primary care provider was contacted to clarify the dosage discrepancy between physician orders and medication administration records.
Deficiencies (1)
| Description |
|---|
| Failed to clarify an order for one resident including an anti-psychotic medication (clozapine) due to lack of documented contact with the primary care provider for dosage clarification. |
Report Facts
Medication tablets on hand: 116
Medication tablets per bottle: 180
Medication dosage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Subject of medication order discrepancy involving clozapine |
| Administrator | Administrator | Interviewed regarding FL-2 form processing and medication order receipt |
| Medication Aide | Medication Aide | Interviewed about medication order verification and FL-2 handling |
| Pharmacist | Pharmacist | Interviewed regarding pharmacy receipt of medication orders and FL-2 forms |
| Mental Health Provider Representative | Mental Health Provider Representative | Interviewed about medication orders and FL-2 completion process |
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 3, 2023
Visit Reason
The Adult Care Licensure Section conducted an annual survey of Springdaile Assisted Living on October 3, 2023.
Findings
The facility was found deficient in medication staff qualifications, medication administration, and accuracy of medication administration records (MAR). Specifically, one medication aide administered medications before passing the required exam within 60 days, one resident did not receive prescribed antipsychotic medication due to lack of order processing and medication availability, and MAR documentation for blood pressure and heart rate monitoring was incomplete and inaccurate.
Deficiencies (3)
| Description |
|---|
| Staff B administered medications without passing the written medication aide examination within 60 days after completing the Medication Competency Validation Clinical Skills Checklist. |
| Medications were not administered as ordered to Resident #1 related to an anti-psychotic medication (quetiapine) which was not available or documented for administration. |
| The medication administration record (MAR) for Resident #1 was inaccurate and incomplete, lacking proper documentation of blood pressure and heart rate checks required for medication administration. |
Report Facts
Number of sampled staff with medication exam issue: 1
Number of sampled residents with medication administration issues: 1
Medication dosage: 25
Medication dosage: 12.5
Medication dosage: 100
Medication dosage: 3.125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Medication Aide | Administered medications without passing required exam within 60 days |
| Administrator | Responsible for ensuring medication aides obtained required documentation and medication orders were entered and administered | |
| Medication Aide/Supervisor in Charge | Medication Aide/Supervisor in Charge | Administered medications and took blood pressure but did not document BP and HR on MAR |
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