Carroll Park Healthcare

In the surveyor’s words

From the most serious findings on record at Carroll Park Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 20, 2023

  Based on review of medical records, facility policies, facility investigation reports, interviews, and observations, it was determined that the facility failed to: 1. Assess known smokers on admission, re-assess residents deemed as safe smokers after they were found to be unsafely smoking, and adequately supervise residents while smoking. 2. Failed to prevent a Resident with documented unsafe use of smoking material from having smoking material in their room. 3. Failed to ensure that a resident's room was free from hazards. This was evident for 8 of 27 residents reviewed for smoking/accidents. […]

• Immediate jeopardy, patternF867Nov 20, 2023

  Based on record reviews and interviews, it was determined that the facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze serious preventable adverse events (SPAE drug overdoses). The first identified occurrence was on [DATE] (Resident #131) which resulted in resident death. Without effective QAPI intervention, 22 additional drug overdose SPAEs occurred (Residents #2, #53, #58, #63, #66, #76, #90, #93, #101, #118, #132, #136, #147, #149, #154, #160, #267, #268, #269, #373, #418, and #420). […]

• Immediate jeopardy, isolatedF678Nov 20, 2023

  Based on observation, interviews, and medical record review, the facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. This was evident for 1 resident (# 266) out of 1 reviewed for CPR initiation. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 3:00 PM on [DATE]. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 7:55 P.M. on [DATE]. The findings include: According to the American Heart Association (AHA) Cardiopulmonary Resuscitation (CPR) is an emergency lifesaving procedure performed when the heart stops beating. […]

• Immediate jeopardy, isolatedF740Nov 20, 2023

  Based on medical record review, review of pharmacy records, review of a facility's program description, and interviews with staff it was determined that the facility: (1) failed to timely implement physician instructions and orders related to SUD treatment, and (2) failed to effectively plan care for residents with Substance Abuse Disorder (SUD) and (3) failed to initiate a Substance Use Disorder care plan for Residents identified with Substance Use Disorders. This was evident for 5 (Residents #147, #90, #101, #141 & #154) of 18 residents reviewed for Substance Use Disorder during survey. These failures contributed to resident overdoses and placed residents at increased risk for serious harm and possible death. The findings include: 1. […]

• Immediate jeopardy, isolatedF626Nov 9, 2021

  Based on a review of the medical record and other pertinent documentation and interviews facility staff, a resident, and hospital staff, it was determined the facility failed to honor a resident's right to return to the facility following the resident's stabilization and treatment after an emergency petition (EP); a decision that was based on the resident's mental state at the time of the EP and the resident's history of incarceration. The facility further failed to evaluate the same resident and determine their ability to meet the resident's needs. This was found to be evident for 1 of 11 residents (Resident #2) reviewed for transfers during a complaint survey conducted at the facility. […]