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Inspection visit

Incident investigation

BROOKDALE KETTLEMAN LANELicense 3970054663 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPAs) Kesha Lewis and Albert Johnson conducted a case management visit as a result of the incident that took place on November 8, 2022. LPA met with the facilities Administrator and explained the purpose of today's visit. The department received an incident report detailing that R1 was given an extra dose of Seroquel 25mg this was a PRN medication and was not listed on the Admissions Orders dated 3/10/22 which contains the PRN information with instructions from R1’s primary care physician. LPAs were unable to review a current PRN letter for R1, because the facility did not have a current PRN letter for R1. During the file review of R1, LPA'S observed that R1 was being treated for rash that was later identified as scabies, (SIR) Special Incident Report was not sent to CCL until 10/04/2022. Rash first identified on June 30, 2022 treatment was given, however unsuccessful and on 8/15/2022 the facility contacted R1's primary physician and started treatment for the rash again. This was also unsuccessful. On 9/28/222 the facility took R1 to urgent care and was given the diagnoses of Scabies. The facility then reported to the Department on 10/4/22 LPA obtained information from R1'S file. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. Exit interview and copy of report provided, appeal rights given.

Citations

3 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(1)(d)Type B

    Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not meet as evidenced by records review LPA'S reviewed R1'S file and found they were being treated for rash that was later identified as scabies, (SIR) serious incident report was not sent to CCL until 10/04/2022. Rash first identified in June 30th 2022. This poses an immediate health and safety risk to residents in care.

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  • 87465(c)(2)Type A

    87465(c)(2) Once ordered by the physician, nonprescription PRN medications shall be given in accordance with the physician’s directions. This requirement was not meet as evidenced by. LPA Received SIR for R1 being given an extra dose of medication.

  • 87465(d)(1Type A

    If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Records reviewed and interviews with the Administrator confirmed that the facility did not have the Physician identify the abilities of R1 to determine her needs for PRN medication as a result the facility administered Seroquel twice as a PRN which was not how the PRN was written. The facility does not have a current list of PRN medications sign by the Physician as to R1’s ability to determine if the medications are needed and whether are not the Physician needed to be contacted prior to or after

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FAQ · About this visit

Common questions about this visit

What happened during the November 21, 2022 inspection of BROOKDALE KETTLEMAN LANE?

This was a other inspection of BROOKDALE KETTLEMAN LANE on November 21, 2022. 3 citations were issued: 2 Type A (serious) and 1 Type B.

Were any citations issued to BROOKDALE KETTLEMAN LANE on November 21, 2022?

Yes, 3 citations were issued (2 Type A, 1 Type B). The first citation was for: "Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limit..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.