Signature Healthcare of Erin

In the surveyor’s words

From the most serious findings on record at Signature Healthcare of Erin, in the surveyor’s own words.

• Immediate jeopardy, patternF602Apr 3, 2024

  Based on policy review, medical record review, facility document review, and interview, the facility failed to ensure residents' rights to be free from misappropriation of controlled narcotics for 7 of 9 (Resident #1, #2, #5, #6, #7, #8, and #9) sampled residents reviewed with orders for controlled narcotics. Resident #1 had a total of 48 tablets of Oxycodone 10 milligram (mg) missing. Resident #2 had a total of 61 tablets of Oxycodone 5 mg missing. Resident #5 had a total of 78 Hydrocodone 7.5 mg tablets missing. Resident #6 had a total of 28 tablets of Oxycodone 5 mg missing. Resident #7 had a total of 94 tablets of Oxycodone 10 mg missing. Resident #8 had a total of 144 tablets of Hydrocodone 5 mg missing. Resident #9 had a total of 56 tablets of Hydrocodone 5 mg missing. […]

• Immediate jeopardy, patternF755Apr 3, 2024

  Based on facility policy review, Pharmacy Services agreement, facility investigation review, review of facility medication reconciliation documents, and interview, the facility failed to have a system of recording, accurate reconciliation, and accounting for all controlled medications, failed to promptly identify loss or potential diversion of controlled medications, and failed to timely determine the extent of loss or potential diversion of controlled medications for 7 of 9 (Resident #1, #2, #5, #6, #7, #8, and #9) sampled residents reviewed with orders for controlled narcotics. On [DATE] the medication nurse (LPN E) discovered that Resident #2's Fentanyl transdermal patch had been tampered with, no actions were taken at that time on [DATE]. […]

• Immediate jeopardy, isolatedF760Apr 3, 2024

  Based on policy review, medical record review, State Medical Doctor Consultant review, and interview, the facility failed to ensure 1 of 9 (Resident #2) sampled residents reviewed for medication administration was free of any significant medication errors. Resident #2's orders for Fentanyl were erroneously changed from being administered every 3 days to being administered daily. Resident #2 was administered Fentanyl patches daily on [DATE], [DATE], and [DATE] when the prescribed order was for the patch to be applied every 72 hours. […]

• Immediate jeopardy, isolatedF689May 1, 2023

  Based on policy review, medical record review, observation and interview the facility failed to provide supervision to ensure a safe environment for a resident with known substance abuse for 1 of 1 (Resident #4) and for a drug seeking resident for 1 of 1 (Resident #7) reviewed. On 1/28/2023, Resident #4 gave his roommate, Resident #7, what was reported to be Tylenol that was not provided by the facility, on 2/15/2023 Resident #4 became lethargic, pupils were pinpoint, and not responding normally, an unlabeled bottle of pills was found in his sock, on 3/10/2023 Resident #4 became lethargic, gray in color, 69% (percent) oxygen saturation (amount of oxygen in the blood) and two doses of Narcan was administered the resident became alert, which resulted in Immediate Jeopardy (IJ) for Resident… […]

• Actual harm, isolatedF697Apr 3, 2024

  Based on medical record review and interview, the facility failed to provide effective pain management for 1 of 9 (Resident #3) sampled residents reviewed for pain management. Resident #3 received Tylenol per physician standing orders, but the Tylenol was not effective as Resident #3 continued to complained of pain. The facility's failure to effectively manage Resident #3's pain and follow up on imaging with continued complaints of pain post fall, resulted in Actual Harm when Resident #3 had a displaced comminuted fracture involving the distal femur. The findings include: 1. […]